ANNEX D

 

REVIEW OF SOLDIER SUICIDES 

Operation Iraqi Freedom (OIF) 

Mental Health Advisory Team (MHAT) 

 

 

16 December 2003 

Chartered by: 

U.S. Army Surgeon General 

This is an annex to the OIF MHAT Report addressing suicide among Soldiers 

deployed to OIF, including Kuwait and Iraq. 

This report is redacted to remove unit identifications, unit locations, and personal 

identity information in accordance with Army Regulation 25-55, Department of the Army

Freedom of Information Act Program, and Army Regulation 340-21, The Army Privacy 

Program. Redacted information appears throughout this report blacked out, such as 

below. 

D-1 
TABLE OF CONTENTS

 

ANNEX D: REVIEW OF SOLDIER SUICIDES........................................................... D-1

Introduction.............................................................................................................. D-3

Findings ................................................................................................................... D-3

Recommendations................................................................................................... D-4

Discussion Of The Findings..................................................................................... D-5

Discussion Of Recommendations.......................................................................... D-16

APPENDIX 1: TABLES ........................................................................................ D-20

APPENDIX 2: METHODS AND PROCEDURES ................................................. D-21

APPENDIX 3: REFERENCES............................................................................. D-22

APPENDIX 4: Army Suicide Prevention – A Guide for Installations and 

Units ..................................................................................................................... D-23

APPENDIX 5: AMEDD Suicide Event Report (ASER), Pilot Version – v. 31 January 

2003 ...................................................................................................................... D-73

D-2 
ANNEX D to OIF MHAT REPORT

INTRODUCTION

The objectives of this review were to identify factors impacting on suicide risk for 

Operation Iraqi Freedom (OIF) Soldiers and make recommendations to assist with 

suicide prevention efforts. Within the first 17 days of July 2003, five suicides occurred in 

Iraq and alerted the leadership of Combined Joint Task Force-7 (CJTF-7), Coalition 

Forces Land Component Command (CFLCC), Army Medical Department (AMEDD), 

and Department of Army (DA) to a potential suicide outbreak. Also within this same 

time period, a Soldier who had left OIF via psychiatric medevac committed suicide 

within days of returning to CONUS. As part of its charter, the OIF MHAT was directed 

to determine whether the July suicides represented a burgeoning suicide rate among 

OIF Soldiers. 

This review provides an analysis of Army suicides occurring in Iraq and Kuwait

between January and October 2003 by male and female Active and Reserve 

Component Soldiers. Although OIF did not commence until mid-March, Soldiers who 

deployed to Kuwait between January and March are included. The suicide rates for 

Soldiers deployed to OIF January – October 2003 were compared to other relevant 

suicide rates, and the characteristics of OIF suicides were studied to determine whether

there are increased risks for suicide associated with OIF deployment. Findings and 

recommendations are presented first, followed by tables, summary of methods, and 

references. 

This review provides a highly proactive suicide risk assessment for a deployed 

military force, conducted during an on-going military operation. There is no known 

precedent for this type of assessment. By its nature, suicide is a low frequency event 

and occurs for highly individualistic reasons. These characteristics present enormous 

challenges for detecting reliable trends among a population that will lead to effective 

prevention actions. The data analyzed for this review are time-sensitive and should be 

interpreted in this context. 

FINDINGS

1. The suicide rate for Soldiers deployed to OIF January – October 2003 was 

higher than recent Army historical rates. 

The OIF suicide rate was 15.6 suicides per 100,000 Soldiers per year for suicides 

occurring between January-October, and compares to the average annual rate of 11.9 

per 100,000 for the eight-year period 1995-2002 (range 9.1 - 14.8). 

2. There was a high incidence of OIF suicide during July when compared to other 

months but it did not signify an escalating rate of suicide. The July OIF suicides 

may be viewed as a spike when compared to the months before and after July, but 

D-3 
there was no continuing trend and no indication that any of the suicides were related to 

each other. 

3. Firearms were the predominant method of suicide for OIF Soldiers. 

Most suicides were committed by young males, a group that is typically high risk for 

suicide. The frequency of firearm suicide during OIF was much higher when compared 

to firearm suicide for the Army and U.S. populations in previous years. The deployed 

force is comprised of a large number of young males who are a group with high suicide 

risk in the U.S. population. 

4. Compared to historical Army suicide rates, OIF suicide rates were higher for 

Soldiers located in Iraq and lower for Soldiers in Kuwait; higher for Active 

Component Soldiers and lower for Reserve Component Soldiers; and higher for 

both males and females. Compared to the average Army suicide rate of 11.9 per 

100,000, the rates for OIF Soldiers assigned in Iraq, females, Active Component 

Soldiers, and males, were 21.2, 19.0, 17.2, and 15.2 respectively. The rates for 

Reserve Component Soldiers and Soldiers assigned in Kuwait were 9.2 and 3.0 

respectively. 

5. Deployment length varied widely for Soldiers who committed suicide. 

One fourth of Soldiers who committed suicide did so within the first thirty days of arriving 

in theater. Transition to deployment may be a contributing stressor for some suicides, 

but vigilance for suicide risk should be maintained throughout a Soldier’s deployment. 

6. In the absence of a standing Army suicide prevention program for tactical 

environments, CJTF-7 and CFLCC created suicide prevention programs. 

The Army Suicide Prevention Program (ASPP) was developed for a garrison-based 

force and provides little guidance for tactical application. The ASPP strategies for 

minimizing suicide risk can be readily adapted to a deployed force engaged in combat 

operations. 

7. OIF behavioral health personnel have utilized traditional but passive suicide 

monitoring that provides limited visibility of suicide risk factors. 

Suicide prevention programs are increasingly using active medical surveillance methods 

to expand the scope of suicide monitoring. New tools are available that monitor serious 

suicide behaviors to improve detection and management of population suicide risk. 

RECOMMENDATIONS

1. Immediate: CFLCC & CJTF-7 should adapt the existing (community-based) 

objectives of the Army Suicide Prevention Program for OIF Soldiers and units. 

Strategies of the ASPP can be applied to a forward deployed force through actions in 

the following five areas: 

D-4 
- Designate proponents to manage the CFLCC and CJTF-7 suicide prevention 

programs 

- Maintain vigilance by leaders and Soldier-peers to ensure Soldiers at risk for 

suicide receive appropriate support 

- Conduct training that provides crisis intervention skills to designated Soldiers

with a goal of one trained Soldier per company 

- Implement surveillance of completed suicides and serious suicide attempts with 

standardized suicide event reporting by behavioral health personnel 

- Establish a command climate that encourages appropriate help-seeking 

behavior by distressed Soldiers. Behavioral health care should be delivered as 

far forward as possible to maximize the likelihood of successfully returning 

Soldiers to duty. 

2. Future: Implement monitoring of serious suicide attempts within Army

medical surveillance systems. Task CHPPM and the OTSG behavioral health 

consultants to develop monitoring of serious suicide attempts at the installation, 

operational, and Army-wide levels. Enough precedence exists to support the 

strategy of reducing suicide occurrence by reducing occurrence of serious suicide 

attempts (leading to hospitalizations and evacuations). A critical component of this 

strategy would be to monitor suicide attempts as a metric for suicide prevention actions. 

The pilot version of the AMEDD Suicide Events Report (ASER) is a promising tool for 

reporting suicide attempts. 

DISCUSSION OF THE FINDINGS

DATA FINDING #1: The suicide rate for Soldiers deployed to OIF January – 

October 2003 was higher than recent Army historical rates. 

Army historical rates. There were 53 suicides within the U.S. Army between January 

and October 2003 which represent an annualized rate of 12.5 suicides per 100,000 

Soldiers per year. The Army suicide rate for the eight-year period 1995-2002 averaged 

11.9 per 100,000 and ranged from a low of 9.1 in 2001 to a high of 14.8 in 1995 

(Appendix 1, Tab A). The Army suicide rate, January – October 2003 is consistent with 

Army suicide rates from previous years. 

OIF suicides. As of 5 December 2003, the Office of the Armed Forces Medical 

Examiner (OAFME) has classified 17 Army deaths occurring within Iraq or Kuwait as 

suicide for Soldiers deployed in support of OIF between January – October 2003 

(Appendix 1, Tab B). In addition, there were two known suicides among Army OIF 

veterans, however they are not included as OIF suicides since their fatal self-inflicted 

injuries occurred after they departed the OIF Theater. 

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OIF suicide rate. The seventeen OIF suicides represent an annualized rate of 15.6 per 

100,000 per year. The current OIF suicide rate is higher than the average annual Army 

rate of 11.9 per 100,000 (range 9.1-14.8). 

Previous military operations. The Army does not calculate suicide rates for specific 

deployments. A review of the professional literature found few references to suicide 

rates during combat or other military operations. One author (Adams, et al, 1998) 

reported an aggregated rate of 15.6 suicides per 100,000 for U.S. military personnel 

during their tour of duty in Vietnam. Other authors (Writer et al, 1996) found a rate of 

3.8 self-inflicted injury deaths per 100,000 personnel from all military branches during 

deployment to Operations Desert Shield and Desert Storm. This wide variation in rates 

serves as a poor baseline against which to compare the current OIF suicide rates. 

DATA FINDING #2: There was a high incidence of OIF suicide during July when 

compared to other months but it did not signify an escalating rate of suicide. 

In July, the monthly incidence of suicides increased nearly threefold from previous 

months, raising concern about a possible outbreak of suicide. Figure 1 displays the 

number of OIF suicides by month along with the monthly rate per 100,000 persons. The 

five OIF suicides in July may be viewed as a spike, but did not signify an escalating rate 

of suicide. When the months before and after July are compared, they are found to be 

highly similar for rate and number of suicide. Although the suicides in July were closely 

associated in time, there was no indication of a contagion effect whereby one suicide 

served as a trigger for another. None of the suicides occurred in the same battalion, 

and they occurred in geographically dispersed locations. However, a suicide did occur 

in late June, eight days prior to the suicide on 2 July at the same base camp and within 

the same Armored Cavalry Regiment (different squadrons). It is possible but unknown 

whether the Soldier who committed suicide on 2 July knew about the suicide on 24 

June. Contributing stressors for the 24 June suicide are cited as financial and personal 

problems while stressors for the 2 July suicide were considered due to marital

problems. 

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Figure 1: Number and Rate of OIF Suicides: Jan-Oct 03

0

1

2

3

4

5

6

Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Number of suicides

0

0.5

1

1.5

2

2.5

3

3.5

Rate per 100,000

per month

Number of suicides Monthly Rate

DATA FINDING #3: Firearms were the predominant method of suicide for OIF 

Soldiers. Most suicides were committed by young males, a group that is 

typically high risk for suicide. 

Sixteen of the 17 suicides (94%) were the result of self-inflicted gunshot wounds, the 

predominant method of suicide for male and female Soldiers. The high frequency of 

firearm suicide stands in contrast to 57% of Army suicides in 2002, and 55.1% of U.S. 

suicides in 2001. Access to firearms is a well-established risk factor for suicide. 

According to the American Association of Suicidology (2003), 85% of U.S. suicide 

attempts by firearms result in a fatality, and the risk for suicide of a household member 

increases nearly five times in homes with guns vs. those without. During deployment to 

OIF, Soldiers routinely have access to loaded weapons and thus a highly lethal means 

for suicide is readily accessible. 

Criminal Investigation Detachment (CID) reports were reviewed to obtain information 

about possible motive for suicide but were incomplete for information about stressors 

contributing to the suicides. Seven of the 17 reports refer to stressors that may have 

contributed to the suicide. Reports for the other ten suicides did not include information 

about possible motives, but were often described as unexpected to fellow Soldiers. The 

stressors that were described are summarized as: Two (2) with marital problems, two 

(2) with legal problems, one (1) with non-specified personal problems, one (1) with 

multiple adjustment problems, and one (1) with financial and personal problems. These 

are the same stressors most often found among Soldier-suicides historically. To the 

extent that these suicides are representative of the other OIF suicides, it appears that 

suicide among OIF deployed Soldiers is occurring for the same reasons typically found 

among Soldier-suicides. It is not clear how many suicides were preceded with the 

warning signs that are typically taught in Army suicide awareness briefings. One 

Soldier clearly communicated specific thoughts of shooting himself to a fellow Soldier, 

D-7 
but no actions were taken to secure the Soldier’s weapon and he shot himself fatally a 

short time later. Given the wider access to weapons however, it would seem that a 

higher number of Soldiers are acting on their thoughts or impulse for suicide before an 

intervention occurs. This indicates a need to emphasize that Soldiers and supervisors 

need to act more aggressively to intervene when are suspected to be at risk for suicide 

or display obvious warning signs. 

Table 3 compares demographic characteristics of OIF Soldier-suicides to Army suicides 

in 2002. The OIF suicide cohort is primarily comprised of young males, a group that 

according to the National Vital Statistics report (2002) is high risk for suicide in the 

United States with twice the rate of suicide in the year 2000 (21.5/100,000 for males 

ages 20-34 vs. 10.7/100,000 national rate). The OIF cohort is more junior in rank with 

fewer married Soldiers but more racial/ethnic minority Soldiers. 

Table 3: Summary Profiles of OIF and Army 2002 Suicides 

As of 5 Dec 03 2003 Army OIF 

Suicides 

2002 Army 

Suicides 

Suicide by firearm/gunshot 94% 59%

Male 88% 98%

Age 30 or younger 82% 63%

E-4 or below 71% 48%

Married 35% 48%

Minority (non-white) 47% 20%

DATA FINDING #4: Compared to historical Army suicide rates, OIF suicide rates 

were higher for Soldiers located in Iraq and lower for Soldiers in Kuwait; higher 

for Active Component Soldiers and lower for Reserve Component Soldiers; and 

higher for both males and females. 

Duty location. Sixteen of the 17 suicides occurred in Iraq. The annualized rate for 

suicide occurring in Iraq is 21.2 per 100,000, and 3.0 for suicide occurring in Kuwait. 

Compared to the Army historical rate, the rate for Iraq is higher and the rate for Kuwait 

is lower. This could be related to wider access to loaded weapons among Soldiers 

assigned in Iraq, and stressors associated with the operational environment in Iraq. 

Component. Fifteen of the 17 suicides were Active Component Soldiers. Compared to 

the historical Army rate of 11.9 per 100,000, the rate for Active Component (AC) is 

higher at 17.2, and the rate for Reserve Component (RC) is lower at 9.2 per 100,000. 

The higher AC rate may largely reflect duty location as discussed above since the 

majority of AC Soldiers are assigned in Iraq. However, there may be protective factors 

D-8 
inherent among USAR and National Guard units such as older age of RC Soldiers or 

stronger social support relationships among unit members. 

Gender. In addition to higher rates among Soldiers deployed to Iraq and Active 

Component Soldiers, a high rate was also documented among female Soldiers. Two of 

the 17 OIF suicides were female and represent an annualized rate of 19.0 per 100,000. 

This rate is higher than the Army historical rate of 11.9 per 100,000, and higher than the 

4.1 per 100,000 rate of suicide among U.S. females in 2001. However, this rate is 

based on only two deaths which does not establish a trend, and should not be 

interpreted as suggesting that there is a particular problem of suicides involving women. 

The annualized rate for the 15 male suicides is 15.2 per 100,000 and although higher 

than the historical Army rate, is lower than the rate of 17.6 per 100,000 for U.S. males in 

2001 (American Association of Suicidology, 2003). 

Risk analysis. It should be noted that suicide rates for small populations are very 

unstable. A small increase in the number of suicides can appear as a disproportionately 

large increase in the rate of suicide. Although it is difficult to compare suicide rates 

between different population groups in OIF, the data suggest that there may be a higher 

risk of suicide for Soldiers assigned in Iraq and for Active Component Soldiers. Further 

surveillance of suicides is essential to determine there are different risk factors for 

subgroups of deployed Soldiers. 

DATA FINDING #5: Deployment length varied widely for Soldiers who committed 

suicide. 

One fourth of Soldiers (25%) who committed suicide did so within the first thirty days of 

arriving in theater but nearly one third (30%) had been deployed more than 120 days 

(Figure 2). Transition to deployment may be a contributing stressor for some suicides, 

but suicides occurred with longer deployment lengths as well. Vigilance for suicide risk 

should be maintained throughout a Soldier’s deployment. 

D-9 
Figure 2: Days in Theater Before Suicide

61-90 days

19%

121+ days

30%

91-120 days

13%

31-60 days

13%

1-30 days

25%

The majority of Soldiers (58%) had been assigned to their unit more than 120 days 

before committing suicide (Figure 3). Over three-fourths (82%) of the Soldiers had been 

assigned more than 60 days. 

Figure 3: Days in Unit Before Suicide

121-180 days

12%

181+ days

46%

61-120 days

24%

1-60 days

18%

DATA FINDING #6: In the absence of a standing Army suicide prevention 

program for tactical environments, CJTF-7 and CFLCC created suicide prevention 

programs. 

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The Army Suicide Prevention Program (ASPP) was developed for a garrison-based 

force and provides little guidance for tactical application. However, the five broad 

strategies of the ASPP for minimizing suicide risk remain relevant and can be adapted 

to a deployed force engaged in combat operations. The five strategies are:

- Develop positive life-coping skills 

- Encourage help-seeking behavior 

- Raising awareness and vigilance 

- Synchronizing, integrating and managing a unit’s suicide prevention program 

- Conduct suicide surveillance, analysis and reporting 

The supporting objectives and tasks to accomplish these strategies need to be tailored 

for a deployed force operating in a hostile environment without normal installation 

support. These objectives can be divided into three main areas, prevention, 

intervention and post-vention. 

Prevention. Suicide prevention strategies are those that help prevent Soldiers from 

considering suicide. They include suicide prevention training, traditionally equated with 

awareness briefings conducted by unit ministry team members, and various resiliency 

programs that help Soldiers deal with the stresses of life. Suicide prevention training 

should continue, although at a smaller unit level than for a garrison force. Training 

should also give first line supervisors skills to recognize symptoms of combat-related 

stress and problems coping in a combat environment. Deployed combat stress control 

teams are ideally suited to accomplish this training. 

Intervention. Regrettably, despite our best efforts, some Soldiers will reach a point 

where they consider suicide. Intervention programs are directed at recognizing these 

Soldiers and protecting them from self-harm until they are referred to a behavioral 

health professional. Applied Suicide Intervention Skills Training (ASIST) is a suicide 

first-aid program that enables Soldiers to recognize when a fellow Soldier is at risk for 

suicide, and employ an intervention model to reduce the immediate risk. The Army has 

targeted those individuals that are most likely to come in contact with a person at risk 

and provide them ASIST. However, for a deployed force, especially in an environment 

where the forces are isolated from mainstream helping agencies, it is recommended 

that every company have a “trusted agent” (a Soldier well respected by others) trained 

in ASIST. This training should be accomplished at the home station prior to 

deployment. However, there are current ASIST trainers deployed with the -------

Detachment that are sponsoring a condensed version of ASIST in a one-day workshop. 

Post-vention. Post-prevention strategies include those policies and programs that help 

survivors of attempted suicide, or provide grief counseling within units where there has 

been a completed suicide. Those who have attempted suicide should receive 

immediate behavioral health treatment to ensure they are protected from further selfharm. Every division or major subordinate command should have a critical event 

response team that can rapidly assist a company/battery level unit cope with loss of a 

D-11
Soldier to suicide. Suicide can have a devastating impact on unit readiness and morale. 

Critical event response teams, comprised of chaplains and behavioral health personnel 

can provide fellow Soldiers with an opportunity to deal with their emotions in a healing 

and helpful way. 

DATA FINDING #7: OIF behavioral health personnel have utilized traditional but 

passive suicide monitoring that provides limited visibility of suicide risk factors. 

When suspected suicides occur in Iraq, the ------- Medical Brigade is notified. Information 

about the Soldier and circumstances of the death are then gathered through informal 

means, generally by requesting information from the behavioral health unit closest to 

where the death occurred. The OIF MHAT found that Division Mental Health and 

Combat Stress personnel generally had limited information about suicides that occurred 

within their supported units except when they had been involved in a post-vention 

response. None of the Soldiers who committed suicide had been in treatment with OIF 

behavioral health providers prior to their suicide. The Army does not require systematic 

review of a completed suicide by a behavioral health officer, but following the high 

incidence of July suicides, the ------- Medical Brigade implemented a new reporting 

process for suicide attempts to better monitor trends and identify potential risk factors. 

This is consistent with the trend among suicide prevention programs to increase use of 

active medical surveillance methods to expand the scope of suicide monitoring. New 

tools are available that monitor serious suicide behaviors to improve detection and 

management of population suicide risk and are discussed below. 

Constellation of suicide behaviors. In addition to the 17 suicides that occurred in Iraq 

or Kuwait, there have been two known suicides among OIF veterans. One of these 

suicides occurred at the CONUS treatment facility where the Soldier was medically 

evacuated for psychiatric treatment. The other suicide occurred nearly four months 

after the Soldier redeployed from OIF. The Soldier allegedly shot and killed a man who 

was vandalizing his vehicle and committed suicide soon thereafter. Both Soldiers had a 

history of psychiatric treatment. Although neither of these two suicides occurred while 

the Soldiers were deployed to Iraq or Kuwait, they are mentioned here due to the 

possibility that OIF-related factors influenced their suicide behaviors. In order to better 

understand and mitigate deployment factors that impact on suicide, the larger 

constellation of suicide behaviors should be considered. This point was made 

persuasively in a recent article by Ritchie et al (2003) that studied psychological 

correlates to suicidal behavior among U.S. military personnel admitted for inpatient 

psychiatric treatment. Persons who commit suicide may communicate warning signs 

prior to committing suicide, or may have a history of suicide attempts, threats, or

gestures. Several psychiatric disorders are associated with increased risk for suicide 

including depression, post-traumatic stress disorder, and alcohol abuse. 

Suicide motive. A review of the CID reports and OAFME autopsy files for the OIF 

suicides provided limited information about motive for suicide. Only a few of the reports 

or files referenced potential contributing problems that included relationship, financial, 

and legal problems. Historically, the majority of Army suicides have been associated 

D-12
with relationship problems. Army psychological autopsies from previous years reflect 

that 75% of Soldier suicides are due to failed intimate relationships, followed in 

frequency by recent or pending UCMJ action (50%) and financial problems (42%). 

Suicide attempts. Attempted suicide increases risk for completed suicide. Nationally, 

the American Association of Suicidology estimates 25 suicide attempts for every 

completed suicide. A potential estimate of the number of suicide attempts among OIF 

deployed Soldiers is available from the OIF MHAT psychiatric medevac data. Ninetyfive (95) of the 527 (18%) Soldiers medically evacuated with a psychiatric diagnosis had 

displayed self-injurious behaviors believed to be suicide attempts or gestures. If it is 

assumed that this number approximates the number of suicide attempts, the ratio for 

OIF is about six suicide attempts for every completed suicide (95 attempts:17 suicides). 

This is lower than the AAS estimate, but occurs in a population that has liberal access 

to health care and a high degree of behavioral supervision. It may also represent a 

higher likelihood that Soldiers who attempt suicide will succeed due to availability of 

loaded weapons as discussed above. The cohort of Soldiers who attempt suicide 

represent “suicide near misses”, and if studied, may provide insight into better 

prevention measures. 

Suicide-related behaviors. Completed suicides may be viewed as the “tip of the 

iceberg” (Figure 4). The MHAT medevac data also provide some indication of 

magnitude of suicide-related behaviors among OIF Soldiers. About 32% of the 527 

Soldiers evacuated from OIF for behavioral health reasons were evacuated with 

elevated suicide risk, and 9% were evacuated with elevated homicide risk. Accounting 

for overlap, about one-third of this group is estimated to have departed theater with 

suicide-related behaviors as part of their clinical presentation. This group constitutes a 

population that should be included in a comprehensive plan to mitigate suicide risk. A

case in point was the completed suicide by one Soldier who had presented with 

symptoms of suicidal ideation prior to psychiatric medical evacuation. 

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Figure 4: Suicide-related Behaviors 

Related Risk

Traditional

Focus

Suicide Ideas

Suicide Gestures

Suicide Attempts

Completed Suicide

TIP OF THE ICEBERG

“The best predictor of future behavior is past behavior.”

Suicide Threats

Depression

Post-traumatic Stress

Substance Abuse

Homicidal Threats

Psychiatric Disorder. Depression is the psychiatric disorder most closely associated 

with suicide; the National Institute of Mental Health (2003) estimates that 60% of those 

who commit suicide in the U.S. are depressed. Combat related post-traumatic stress 

disorder is also linked to increased suicidality (Freeman et al, 2000). The Soldier Wellbeing survey identified higher than expected levels of post-traumatic stress among OIF 

Soldiers and significant levels of depression and anxiety. As the prevalence for these 

disorders increase within a population, presumably the risk for suicide behaviors also 

increases and would warrant more aggressive suicide prevention measures. This 

underscores the importance of active outreach efforts by OIF behavioral health 

personnel. 

Suicide monitoring. Multiple Department of Defense (DoD) and DA agencies monitor 

suicide occurrence within the scope of their missions. None of the current monitoring 

processes is suitable as a health surveillance program for detecting trends and patterns 

of suicide behaviors. A comprehensive suicide prevention program should actively 

monitor serious suicide behaviors that have significant impact on health status or duty 

availability. Monitoring serious suicide attempts, for example, in addition to completed 

suicides could improve management and prevention of the constellation of suicide 

behaviors. 

U.S. Army Criminal Investigation Command (USACIC). The USACIC investigates 

Soldier deaths to exclude other causes of death before making a determination of 

suicide. Criminal Investigation Detachment (CID) field agents conduct the 

investigations by analyzing crime scene evidence, reviewing autopsy findings, forensic 

medical tests, and conducting interviews with informants to determine the Soldier’s state 

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of mind at time of death. It often takes several months to complete the investigation and 

make a final ruling of suicide. Although locally maintained CID case files can contain 

useful information about suicide motive, it would not be practical to utilize CID case files 

for health surveillance purposes. 

Office of the Armed Forces Medical Examiner (OAFME). The OAFME is a division 

of the Armed Forces Institute of Pathology (AFIP) and maintains an archive of DoD 

completed suicides. For military deaths, a forensic pathologist renders an opinion about 

the manner of death based on autopsy results and USACIC case information. Once a 

medical examiner determines manner of death to be suicide, OAFME tracks the suicide 

through its Mortality Surveillance Division. Mortality reporting such as this does not 

include suicide behaviors nor does it “push” information about suicide occurrence to 

other agencies. Similar to USACIC investigations, OAFME medical examiner 

investigations can require several weeks or months to complete. The mortality 

surveillance system is not conducive to monitoring suicide behaviors or conducting 

population health surveillance for suicide risk. 

U.S. Army Human Resources Directorate. The Human Resources Directorate, (a 

division of the Army G-1) monitors Army suicide numbers and rates by coordinating with 

the Office of the Armed Forces Medical Examiner, USACIC and Human Resources 

Command. Through its Suicide Prevention Program Manager, Army suicide rates and 

numbers are shared through MACOM Suicide Prevention Program Managers and an 

informal network of various contacts including Army ASIST trainers, and those trained at 

the Army Suicide Prevention Training Program. These rates are also reported to 

various DA leaders through the Army G-1 and Director of the Army Staff. The program 

manger does not classify manner of death, and will rely on one of the sources 

mentioned above for inclusion as either a “pending” (which is monitored until the status 

is determined) or confirmed as suicide. 

U.S. Army Medical Command (MEDCOM). MEDCOM’s Center for Health Promotion 

and Preventive Medicine (CHPPM) is the DoD proponent for health surveillance. Army 

medical surveillance is conducted as a CHPPM function, utilizing the Reportable 

Medical Event System (RMES). This system primarily monitors communicable disease, 

however it includes other types of reporting such as heat and cold injury. Suicide 

behaviors are not considered reportable events; there are no behavioral or psychiatric 

disorders currently defined as reportable medical events. 

Including suicide attempts that result in hospitalization or suicide attempts that 

result in air evacuation from the operational theater in medical surveillance would 

dramatically increase their visibility and lead to greater emphasis on their 

prevention. Better coordination between agencies is also needed, given that it 

sometimes takes considerable time to resolve manner of death determinations. 

Improved suicide prevention efforts will require Army health surveillance to 

develop accurate population denominators to assure that rates can be 

systematically monitored over time in subpopulations, such as by gender, and 

among reserve and active component Soldiers. 

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U.S. Air Force. In 1994, the Air Force implemented reporting of non-fatal self-injurious 

events and in 2002 reconfigured their database to improve suicide monitoring. The Air 

Force report form served as a model for a similar Army Medical Department (AMEDD) 

form discussed below. According to the USAF Suicide Prevention Program manager, it 

took several years to build the database that now provides monthly reports to major 

commands for comparing current suicide occurrence with previous years. A three-year 

university contract was recently awarded to study risk factors from the database. 

AMEDD Suicide Event Report (ASER). In June 2001, DoD policy changed 

requirements for psychological autopsy from a routine report for all suicides, to a 

forensic investigation when manner of death is equivocal. To preserve surveillance of 

suicidal behavior the AMEDD, in conjunction with the Army G-1, developed the ASER 

(Appendix 5) to record demographic data and psychological correlates from Soldiers 

with suicide behaviors. The ASER is envisioned to feed a database that will permit 

analysis of trends and risk factors for suicide. Although not yet released for Army-wide 

implementation, it has been used locally at selected installations to improve 

management of Soldiers with suicide-related behaviors. The ASER promises to 

increase understanding of Soldier motives for suicide and elucidate contributing 

stressors, if it is used consistently to track completed suicides and serious suicide 

attempts (those that result in evacuation or hospitalization). 

The OIF MHAT was only able to obtain limited information about psychosocial factors 

related to the OIF suicides, gleaned from initial CID reports and medical autopsy files. 

Consistent with current Army policy, there were no psychological autopsies or other 

reviews conducted by behavioral health personnel following OIF suicides. Likewise, 

there is no systematic tracking of OIF suicide attempts through medical channels. The 

ASER is a reporting tool that has already been developed and is the pilot version is 

available for immediate use. This is a tool that seems to offer OIF behavioral health 

personnel a useful means to monitor trends among Soldiers with suicide behaviors. 

DISCUSSION OF RECOMMENDATIONS

 

RECOMMENDATION #1: Immediate: CFLCC & CJTF-7 should adapt the existing 

(community-based) objectives of the Army Suicide Prevention Program to OIF 

Soldiers and units. Strategies of the ASPP can be applied to the OIF force through 

actions in the following five areas: 

Proponency. One key component of a deployed force’s suicide prevention program is 

to assign a proponent that manages, coordinates and synchronizes the program for the 

commander within their theater of operations. Suicide prevention involves many 

professions and staffs (behavioral health professionals, chaplains and chaplain 

assistants, human resource officers, civilian helping agencies, emergency first 

D-16
responders, trial defense lawyers, public affairs), many of whom are operating within the 

OIF areas of operation. The proponent should host periodic working group meetings 

involving responsible agents and staff members to focus attention towards achieving the 

Army’s goal of minimizing the risk of suicide for their Soldiers. Each division or separate 

brigade should have its own suicide prevention proponent that coordinates the efforts 

within their respective units and ensure their plan is nested within the theater’s suicide 

prevention plan. All managers should report on a routine basis to their commander on 

their estimated risk level for suicide. 

Awareness. Maintaining awareness and vigilance is especially crucial for a deployed 

force. All leaders and first line supervisors must maintain awareness and vigilance 

towards their suicide prevention efforts. Major subordinate command senior leaders 

should emphasize their suicide prevention programs throughout their respective 

leadership channels. Junior leaders should be equipped with the skills to help them 

identify when one of their Soldiers is having difficulty adjusting to the stresses of an 

extended deployment within a combat zone. Combat Stress Control teams are located 

throughout the region and are available to conduct such training. First-line supervisors 

should also be vigilant for stressors their Soldiers are receiving from home. Personal 

relationship problems, financial problems and legal actions have been some of the 

common triggers for Soldiers contemplating suicide.

Training. Commanders should also ensure that they have sufficient ASIST trained 

personnel within their units. ASIST is very similar to the Army’s combat lifesaving 

program, with the focus on identifying whether or not someone is at risk for suicide, and 

then if warranted, applying a proven intervention model that protects the individual until 

the chain of command or a behavioral help professional can assist. One of the 

objectives of the Army Suicide Prevention Campaign Plan is to target those who are 

most likely to come in contact with a person at risk for suicide to receive the ASIST 

training. In a deployed force, those who should have the training include all unit ministry 

team (UMT) members, selected defense trial lawyers, and any civilian-helping agency 

such as the American Red Cross. Given the isolation of the deployed forces, it would 

be ideal to identify additional trusted individuals, at least one per company/battery, to 

receive the training and assist with identifying Soldiers at risk for suicide. Normally 

ASIST is taught in a two-day workshop. However, the US Army has received 

permission from Living Works Education (LWE), the proprietor that developed ASIST, to 

condense the training into one day for OIF. There are certified Army trainers currently 

serving with the ------- in Iraq that are able to conduct the training. 

Surveillance. Commanders should maintain situational awareness towards suicides 

and suicidal behaviors within their force. This awareness should include more than just 

a numeric count, but also include an understanding of suicidal risk factors that might 

influence behavior within their commands. This includes those factors that minimize the 

risk (available support and helping agencies) and those that increase risk (access to 

lethal means). As with other fatalities, commanders should ensure that all completed 

suicides and serious suicide attempts are reviewed to determine if there are “lessons 

learned” to prevent similar events from occurring in the future. These lessons learned 

D-17
should be shared throughout the command. By maintaining awareness, the various 

staffs can also determine if there are possible trends or related factors for the causes or 

reasons behind the suicide or suicide attempt. If such trends are identified, appropriate 

counter-measures can be explored to mitigate the risk. 

Commanders should also be informed when the rate of serious suicidal behavior among 

their Soldiers exceeds normal Army rates. Although every suicide is a tragic and 

unnecessary loss, it is unrealistic to expect that any commander of a large force can 

completely eliminate suicide behavior from their ranks. Therefore, suicide rates 

presented to the commanders should be presented in the context of other Army rates 

(based upon similar demographics) for comparison. 

Help-Seeking Behavior. Encouraging help-seeking behavior is a leader responsibility 

at all levels and is especially important for a force deployed away from normal support 

agencies and systems (family, church, civilian health care, etc). Leaders should 

encourage help seeking behavior as a sign of individual strength and maturity. The first 

step is for leaders to understand themselves what services are available within their 

area of operations and the protocols for their use. Commanders of helping 

units/agencies or personnel who provide counseling and or assistance to Soldiers 

should strive to make their units/personnel available within the constraints of the forceprotection plan. All first line supervisors should maintain a positive influence and 

presence within the lives of their Soldiers and anticipate when a Soldier needs

assistance by knowing when the Soldiers is facing a crisis from home, or is not handling 

the stresses of the deployment well. The goal is to refer the Soldier for assistance 

before crisis becomes overwhelming. Soldiers should be informed that most problems 

can be handled in either an informal (meeting with unit chaplain) or even formal 

(meeting with a behavioral health professional) without any impact on their Army career. 

D-18
RECOMMENDATION #2: Future: Implement monitoring of serious suicide 

attempts within Army medical surveillance systems. Recommend tasking 

CHPPM and the behavioral health consultants to develop capability for 

monitoring serious suicide attempts at the installation, operational, and Armywide levels. 

There is little precedent for actively monitoring suicide behaviors as part of population 

health surveillance, however enough precedence exists to support the strategy of 

reducing suicide occurrence by reducing the occurrence of serious suicide attempts 

(leading to hospitalizations and evacuations). A critical component of this strategy is the 

monitoring of suicide attempts an outcome metric for suicide prevention actions. It is 

impractical to monitor all suicide attempts for several reasons. First of all, many 

attempts are very minor (scratching skin, taking a few additional tablets of a medication,

etc.). It is often difficult to distinguish gestures that did not include the intention to die 

from true attempts. It would overly burden behavioral health providers to report every 

attempt or gesture. However, a reasonable approach would be to document severe 

attempts defined as those that result in hospitalization or evacuation. The Air Force has 

led the way in developing a suicide event reporting system that includes non-fatal selfinjurious behavior. However, this is a passive surveillance system that relies on 

clinician reporting and likely significantly underestimates the true rate of attempts. 

FORSCOM monitors suicide attempts and gestures on a quarterly basis as part of its 

Risk Reduction Program. This generally also relies on clinician reporting at the military 

treatment facility. At the installation level, Ft. Lewis has utilized the pilot version of the 

ASER to develop baseline rates for suicide attempts and help monitor suicide 

prevention efforts (Crow, 2003). 

Several obstacles need to be overcome for monitoring suicide behaviors. Army-wide 

medical surveillance requires ICD-9 coded events which are not specific for suicide 

attempt. The ASER is poised for wider utilization but will require publicity and training to 

implement. There is currently no provision for creating and maintaining a database to 

archive ASER results, and no provision for developing capability to analyze ASER data 

for trends and risk factors. A monitoring system will need to push information to the 

behavioral health, medical, and Command leadership as a metric for suicide prevention 

actions. 

The Army behavioral health consultants should collaborate with CHPPM to develop 

capability for this type of monitoring. Serious suicide attempts (that result in 

hospitalizations or evacuations) should be included within Army medical surveillance as 

reportable medical events analogous to communicable disease and other reportable 

events. The lessons learned from Air Force, FORSCOM, Ft. Lewis, and other local 

efforts should be harnessed to create installation level and Army-wide systematic 

monitoring of these suicide behaviors. 

D-19
APPENDIX 1 (Tables) to ANNEX D to OIF MHAT REPORT 

TAB A: U.S. Army Suicide Rates: 1995-2002 

Calendar Year Rate per 100,000 

1995 14.8 

1996 12.4

1997 10.6

1998 12.0

1999 13.1

2000 12.1

2001 9.1 

2002 11.1

Average all years 11.9 

TAB B: Profile of Confirmed OIF Suicides (as of 5 Dec 03) 

Date of suicide Age Rank MOS Comp Gender Race/Ethnicity Married Method 

--------- ---- E-4 92G AC M H -- ------- 

--------- ---- E-4 95B AC M B -- ------- 

-------- ---- E-5 11B AC M W -- ------- 

-------- ---- E-2 11B AC M W -- ------- 

--------- ---- E-4 77F AC M B -- ----- 

--------- ---- E-4 92G AC M B -- ------- 

------- ---- E-3 98C AC M W -- ------- 

------- ---- E-6 92A AC M B -- ------- 

------- ---- E-5 92A AC F O -- ------- 

--------- ---- O-3 38A RC M W -- ------- 

--------- ---- E-5 93C AC M W -- ------- 

-------- ---- E-3 12B AC M W -- ------- 

--------- ---- E-3 12B AC M H -- ------- 

--------- ---- E-4 97E AC F W -- ------- 

--------- ---- E-4 13D AC M W -- ------- 

--------- ---- E-3 92Y AC M W -- ------- 

--------- ---- E-2 12B RC M B -- ------- 

D-20
APPENDIX 2 (Methods and Procedures) to ANNEX D to OIF MHAT REPORT 

1. OIF suicides were defined as those Army Active or Reserve Component deaths for 

which the fatal self-inflicted injury occurred in Iraq or Kuwait between 1 January 2003 

and 31 October 2003, and for which the Office of the Armed Forces medical examiner 

has determined the manner of death to be suicide. 

2. Information about the Soldiers from the suicide cohort was obtained from casualty 

reports, personnel records, CID reports, and the medical examiner records. There were 

no psychological autopsies or other reports from behavioral health personnel for the 

suicides occurring in Iraq or Kuwait. Behavioral health records were reviewed for the 

two OIF veterans who committed Soldiers after they left the OIF theater. 

3. Suicide rates are reported by convention as the number of suicides per 100,000 

persons. Monthly suicide rates were calculated by multiplying the number of suicides 

each month by 100,000 and dividing by the number of Soldiers in the OIF theater. The 

denominators used were force strength numbers at the end of each month, January 

though October 2003, for male and female active and reserve component Soldiers 

assigned to Kuwait and Iraq. In order to compare OIF rates to other annual rates, yearto-date rates were annualized by dividing the cumulative number of suicides by total 

person-years (cumulative person-months over the 10 month period divided by 12). 

Poisson analyses were conducted to determine if the number of OIF suicides 

statistically differed from historical rates (probability <.05). 

D-21
APPENDIX 3 (References) to ANNEX D to OIF MHAT REPORT 

1. Adams, DP, Barton, C, Mitchell, L, Moore, AL, Einagel, V. Hearts and Minds: 

Suicide Among United States Combat Troops in Vietnam, 1957-1973. Social Science 

Medicine 1998;47:1687-1694. 

2. Writer, JV, DeFraites, RF, Brundage, JF. Comparative Mortality Among US Military 

Personnel in the Person Gulf Region and Worldwide During Operations Desert Shield 

and Desert Storm. JAMA 1996;275:118-121. 

 

3. Suicide by Firearms: Research Data and Prevention Recommendations. Retrieved 

October 28, 2003, from American Association of Suicidology website: 

http://www.suicidology.org 

4. National Vital Statistics Report, Vol. 50, No. 16, September 16, 2002. Retrieved 

October 28, 2003 from the National Center for Health Statistics website: 

http://www.cdc.gov/nchs/index.htm 

5. U.S.A Suicide: 2001 Official Final Data. Retrieved October 28, 2003, from American 

Association of Suicidology website: http://www.suicidology.org 

6. Ritchie, EC. Suicidal Admissions in the United States Military. Military Medicine

2003;3:177-181. 

7. Freeman, TW, Roca, V, Moore, WM. A Comparison of Chronic Combat-Related 

Posttraumatic Stress Disorder (PTSD) Patients with and without a History of Suicide 

Attempt. Journal of Nervous and Mental Disease 2000;188:460-463. 

8. Frequently Asked Questions about Suicide. Retrieved November 13, 2003, from the 

National Institute of Mental Health website: 

http://www.nimh.nih.gov/research/suicidefaq.cfm 

9. Crow, BC. Ft. Lewis Suicide Prevention 1998-2003, the Quest for Best Practices. 

6th Annual Force Health Protection Conference, Albuquerque, New Mexico 14 August 

2003. 

D-22
APPENDIX 4 (Army Suicide Prevention-A Guide For Installations and Units-Draft 

2002 Version) to ANNEX D to OIF MHAT REPORT 

 

D-23
Headquarters, Department of the Army, G-1 

Army Suicide Prevention – A Guide 

for Installations and Units 

D-24
 

Army Suicide Prevention – A Guide for Installations and Units 

1. The Army’s strength rests with our Soldiers, civilians, retirees, and their families, 

each being a vital member of our institution. Suicide is detrimental to the readiness of 

the Army and is a personal tragedy for all those affected. Therefore, suicide has no 

place in our professional force! 

 2. We all realize the inherent stress and burdens placed upon our Soldiers, civilians 

and their family members. What defines us as an institution is our compassion and 

commitment to promoting a healthy lifestyle by emphasizing physical, spiritual and 

mental fitness. This contributes to the overall well-being of the force and readiness of 

the Army. Therefore, we must remain cognizant of the potential suicidal triggers and 

warning signs so that we can raise awareness and increase vigilance for recognizing 

those whom might be at risk for suicidal behaviors. Furthermore, we must create a 

command climate of acceptance and support that encourages help-seeking behavior as 

a sign of individual strength and maturity. 

3. Suicide prevention, like all leadership challenges, is a commander’s program and 

every leader’s responsibility at all levels. However, the success of the Army Suicide 

Prevention Program (ASPP) rests upon proactive, caring and courageous Soldiers, 

family members and Army civilians who recognize the imminent danger and then take 

immediate action to save a life. We need your help to minimize the risk of suicide within 

the Army to stop this tragic and unnecessary loss of human life. Suicide prevention is 

everybody’s business and in The Army, EVERYONE MATTERS! 

 

 Lieutenant General, GS 

 Deputy Chief of Staff, G-1

D-25
 

Headquarters 

Department of the Army 

Washington, DC 

Army Suicide Prevention – A Guide for Installations and Units

Summary. This booklet contains the 

framework to build and organize suicide

prevention programs within Army 

Installations. It represents a refinement of

the Army Suicide Prevention Program 

(ASPP) as currently prescribed in AR 600-

63 and DA PAM 600-24. It explains new

initiatives and offers recommendations,

strategies and objectives for reducing the 

risk of suicidal behavior within the Army. 

Suggested Improvements. The proponent 

agency of this program is Headquarters,

Department of the Army, G-1. Users are

encouraged to send comments and

suggested improvements directly to DAPEHRP, 300 Army Pentagon, Room 2B659,

Washington D.C. 20310-0300, ATTN: The

Army Suicide Prevention Program Manager. 

D-26
CONTENTS

(listed by paragraph number) 

Chapter 1 Chapter 4 Chapter 6 

Introduction Prevention Secure 

Magnitude of the Problem, 1-1 Identifying High Risk Individuals, 

4.1 

Safeguard, 6.1

ASPP Goal, 1-2 Behavioral Health Treatment, 6-

CSA Statement, 1-3 Caring and Proactive Leaders, 2 

4.2 Behavioral Health Assessment, 

Chapter 2 Encouraging Help Seeking 6-3 

Understanding Suicide Behavior, 4.3 

Behavior Teach Positive Life Coping Chapter 7 

Skills, 4.4 Post-intervention Measures

A Model for Explaining 

Dysfunctional Behavior, 2-1 Chapter 5 Installation Suicide Response

Mental Disorders, 2-2 Intervention Team, 7-1 

Developmental History, 2-3 Army Suicide Reporting 

Influence of the Current Procedures, 7-2 

Environment, 2-4 

Suicide Awareness and 

Vigilance, 5-1 Army Completed

Suicide Triggers, 2-5 Applied Suicide Intervention 

Reasons for Dying, 2-6 Skills Training (ASIST), 5-2 

Suicide Danger Signs, 2-7 Five Tiered Training Strategy, 5-

3 

Annex A - Strategy Matrixes 

Suicide Warning Signs, 2-8 Annex B - Checklists 

Resources for Living, 2-9 All Soldiers Training, 5-3a Annex C - Suicide Risk 

Leaders Training, 5-3b Comparison of Age Cohorts 

Chapter 3 Gatekeepers Training, 5-3c Annex D – Definitions 

The Army Suicide Prevention 

Model 

Unit Ministry Team Training, 5-

3d 

Annex E – Abbreviations/ 

Acronyms 

Combat Stress Control Teams, 

5-3e 

Annex F – References 

General Overview, 3-1 Annex G – Useful Web Sites 

Prevention, 3-1a Mental Health Care Professional 

Intervention, 3-1b Training, 5-3f 

Secure, 3-1c USACHPPM Suicide Prevention 

Continuity of Care, 3-1d Resource Manual, 5-4 

Installation Suicide Prevention 

Committee, 5-5 

ASPP Accountability, 5-6 

D-27
Chapter One – Introduction 

“A leader is a dealer in hope”

Napoleon 

1-1. Magnitude of the Problem 

During the 1990’s, the Army lost an equivalent of an entire battalion task force to suicides (803 

Soldiers). This ranks as the third leading cause of death for Soldiers, exceeded only by 

accidents and illnesses. Even more startling is that during this same period, five-times as many 

Soldiers killed themselves than were killed by hostile fire. 

To appreciate the magnitude and impact of suicide, consider that most suicides have a direct, 

lasting impact on between 6-7 intimate family members (spouse, parents, children), and 

numerous others including relatives, unit members, friends, neighbors, and others in the local 

community. 

1-2. Army Suicide Prevention Program Goal 

The goal of any Army Suicide Prevention Program is to minimize suicidal behavior among our 

Soldiers, retirees, civilians and family members. Suicide behavior includes self-inflicted 

fatalities, non-fatal self-injurious events and suicidal ideation. 

Suicide prevention is an evolving science. It is our responsibility to utilize the best-known 

available methodology in caring for our Soldiers, retirees, civilians and family members. The 

success of our efforts will be measured by the confidence and conscience of knowing that: 

9 we have created and fostered an environment where all Soldiers, civilians and family 

members at risk for suicide will quickly be identified and receive successful intervention 

and appropriate care; 

9 where help-seeking behavior is encouraged and accepted as a sign of individual 

strength, courage and maturity, and; 

9 where positive life-coping skills are taught and reinforced by all leaders. 

1-3. CSA Statement 

In 2000, following a 27% increase in the number of reported suicides within the Army during 

1997-1999, the CSA, General Eric K. Shinseki, stated that suicide is a “serious problem” and 

directed a complete review of the ASPP. He called for a campaign that would refine the ASPP 

by making use of the best-known available science, and would also invigorate suicide 

prevention awareness and vigilance. He further stated that for the program to be effective, the 

framework must: 

• involve all commanders 

• be proactive 

• intensify preventive efforts against suicidal behavior 

• invest in our junior leaders 

• improve current training and education

D-28
 

Chapter Two - Understanding Suicide Behavior 

“We cannot possess what we do not understand.” 

Goethe 

2-1. A Model for Explaining Dysfunctional Behavior 

A Model for Understanding 

Dysfunctional Health-Risk Behaviors

 Visible to

 Command

“Outcome” & 

 Consequences

 - Schizophrenia 

 - Mania 

 - Depression 

 - Substance Abuse

- Consequences of Abuse -Trauma 

 - Adverse Childhood Experiences

Work & Home Environments 

 -supportive vs. non-supportive

“Triggers” for Dysfunctional

 Behavior 

NOT Visible 

to Command

Behavio

r 

Stressors

Current 

Environment

FIGURE 1

Genetic Vulnerability

to 

Psychiatric Illness 

Developmental 

History

Human behavior is an action 

influenced by one’s genetic 

composition, shaped by 

developmental history, and 

usually as a reaction to a

particular stimulus within the 

environment. The model 

provided in Figure 1

graphically illustrates how 

one’s genetics, background 

and current environment can 

contribute to dysfunctional 

behavior. Some individuals 

are born predisposed towards 

psychiatric illness and/or

substance abuse, which makes 

them more susceptible or

vulnerable for certain types of 

dysfunctional behavior, including 

suicide. Childhood experiences 

filled with abuse, trauma, and/or neglect during the crucial, formative stages of personal 

development will also have a detrimental affect on the development of positive life-coping s

A “non-supportive environment,” whether at work or home, filled with stress, resentment, 

ridicule, or ostracized from family or friends, might also be conducive to dysfunctional

kills. 

behavior. 

Leaders should realize that Soldiers and civilians enter into the Army with varying levels of lifecoping skills and resiliency as determined by their genetic disposition, developmental and 

environmental influences. Leaders should not assume that all Soldiers and civilians entering 

the Army can adequately handle the inherent stress of military service or even life in general, 

especially if they are already predisposed to psychiatric disorder. Although it is unrealistic for a 

leader to understand the genetic composition of the Soldier and civilian, or know their complete 

developmental history, leaders can make proper assessments of their life-coping skills by 

observation and personal dialogue focused on learning and understanding the Soldier’s 

background. This chapter is designed to explain the causes of suicide and inform leaders of 

common danger and warning signs so they can properly anticipate suicidal, or other 

dysfunctional behavior, and make preemptive referrals to professional mental health care 

providers before a crisis ensues. 

2-2. Mental Disorders. 

Mental disorders “are health conditions that are characterized by alterations in thinking, mood, 

or behavior, which are associated with distress and/or impaired functioning and spawn a host of 

human problems that may include disability, pain, or death.”1 Mental disorders occur throughout 

society affecting all population demographics including age, gender, ethnic groups, educational 

D-29
background and even socioeconomic groups. In the United States, approximately twenty-two 

percent of those between the ages of 18 – 64 years had a diagnosis of some form of mental 

disorder.2 Mental illness is more common than cancer, diabetes, or heart disease, filling almost 

21 percent of all hospital beds at any given time. In fact, the number one reason for 

hospitalizations nationwide is a biological psychiatric condition. Mental disorders also affect our

youth. At least one in five children and adolescents between 9 – 17 years has a diagnosable 

mental disorder in a given year, about five percent of which are extremely impaired. 

Mental disorders vary in severity and disabling effects. However, current treatments are highly 

effective and offer a diverse array of settings. The treatment success rate for schizophrenia is 

sixty percent, sixty-five percent for major depression, and eighty percent for bipolar disorder. 

This compares to between 41-52 percent success rate for the treatment of heart disease. 

In 1996, the Assistant Secretary of Defense for Health Affairs commissioned Dr. David Schaffer, 

a leading authority on suicide prevention, to analyze the Department of Defense Suicide 

Prevention Programs. He completed his study that included an in-depth analysis of each 

service suicide prevention program, in 1997. A key point stressed by Dr. Schaffer was that 

most suicides are associated with a diagnosable psychiatric disorder such as depression and/or 

substance abuse. These disorders generally manifest themselves in some form of clinical

depression, a disorder that can increase suicidal risk (often in combination with substance 

abuse), anxiety, impulsiveness, rage, hopelessness and/or desperation. 

Although it is the responsibility of the professional mental health care provider to diagnose a 

mental disorder, there are certain behaviors that indicate an underlying mental disorder. 

Leaders should be cognizant of these warning behaviors that might indicate the presence of a 

mental disorder which place Soldiers at risk for suicide or other dysfunctional behavior. They 

are: 

• impulsiveness or aggressive-violent traits, 

• previous other self-injurious acts, 

• excessive anger, agitation, or constricted preoccupations, 

• excessive alcohol use, 

• heavy smoking, and 

• evidence of any sleep or eating disorder. 

 

Leaders who spot such behavior and/or suspect that one of their Soldiers or civilians is suffering 

from a mental disorder should notify their chain of command so that the commander can decide 

upon making a referral to a mental health care provider. It is important to note that persons with 

mental disorders are often unable to appreciate the seriousness of their problem, as the 

disorder frequently distorts their judgement. Therefore, they must rely upon others for 

assistance. 

2-3. Developmental History

Developmentally, the home/family environment where reared will influence one’s behavior. 

Unfortunately, many of today’s youth are growing up in “non-traditional” homes, without two 

consistent parenting figures. This can be detrimental to the development of “well-adjusted” 

individuals capable of handling life’s general stresses and potentially lead to dysfunctional 

behavior, including suicide. According to Tondo and Baldessarini,3 the suicide rate for 

America’s youth is higher in single-parent families, especially when the father is not present. 

D-30
This is particularly alarming considering that over 40% of the youth today are from “nontraditional” homes,4 which could explain why the suicide rate among America’s youth is rising. 

Childhood abuse or neglect might also adversely affect the positive development of life-coping 

skills and lead to dysfunctional behavior. A research article released in 1998 by the American 

Journal of Preventive Medicine commonly referred to as “The ACE Study,” (adverse childhood 

experiences) stated that there was a “strong graded relationship between the breadth of 

exposure to abuse or household dysfunction during childhood and multiple risk factors for 

several of the leading causes of death.”5 These adverse childhood experiences include 

psychological, physical or sexual abuse, and exposure to dysfunctional behaviors including 

living with a substance abuser, someone with a mental illness, domestic abuse, or criminal 

activity. As exposures to ACEs increased, so did the risk of several health-related problems 

including smoking, obesity, depression, use of illegal drugs, promiscuity, and even suicide. 

According to Legree6 in a report published in 1997, the consequences of these adverse 

childhood experiences could cause friction within the Army as those recruits that have been 

abused can:

• have a significant distrust of authority figures, 

• have an over-reliance on self, 

• tend to form sexualized relationships prematurely, 

• have a increased risk for substance abuse, 

• not easily transfer loyalty to institutions such as the Army, and 

• have a “me-oriented” attitude, often seeking short-term payoffs. 

Other studies indicate that adverse childhood experiences may be prevalent within our recruits. 

A U.S. Naval Behavioral Health Research Study released in 1995 reported approximately 40% 

of all Naval recruits self-report having been raised in homes where they were physically and/or 

sexually abused and/or neglected.7 In the same study, 45.5 percent of all female recruits 

reported having a sexual assault before entering the service. 

Although today’s youth tend to be more technologically astute than previous generations, 

generally they have less developed relationship skills, especially in anger management. With 

the prevalence of personal computers and multiple televisions within the household, many of 

American’s youth are spending less time personally interacting with others, which can lead to 

deficiencies in the development of healthy social skills. As with physical and mental skills and 

abilities, recruits enter the Army with varying levels of social and life coping skills. A prudent 

leader will recognize this fact, attempt to assess those assigned to his or her care, and 

determine who might require remedial assistance and mentoring. 

2-4. Influence of the Current Environment 

The Army’s opportunity for intervention and influencing behavior begins when the Soldier or 

civilian reports to initial entry training (IET) (or equivalent) and lasts beyond their term of service. 

This intervention can either have a positive or negative influence on their behavior. Small unit 

leaders should strive to positively impact constructive life coping skills and create an 

environment filled with support, respect and acceptance, where individuals feel they are an 

integral part of a team. This supportive environment can potentially block certain types of 

dysfunctional behavior by providing Soldiers and civilians a support system and adequately 

equipping them to properly handle life’s stressors. The results or reward of a supportive 

environment (represented in the top left “output” box in Figure 2) will be a better-adjusted 

individual. Conversely, if the small unit leader creates an environment where negative life 

D-31
coping skills are reinforced or positive life coping skills are ignored, such an environment could 

then possibly contribute to dysfunctional behavior (represented in the top right “output” box in 

Figure 2). 

Small unit leaders have the most crucial role in establishing and determining the conditions of 

the Soldier and civilian’s work environment. These leaders should strive to have a positive 

influence on them by being a proper role model for them to emulate. For some Soldiers and 

civilians, their role and camaraderie within their unit and the relationship with their first line 

supervisor might be the only positive, life-sustaining resource available to them in times of 

adversity. Therefore, everyone should take this responsibility seriously. 

Senior leaders are responsible for the development of junior leaders to ensure that they are 

aware of the importance of being a proper role model and fostering a positive work environment. 

Commanders and senior Non-commissioned officers and civilian leaders should constantly 

assess their junior leaders’ ability to positively influence behavior. It could be a disastrous 

mistake to assume that all junior leaders are reinforcing positive life coping skills in the presence

of their Soldiers and civilians, especially considering that over half of the Army suicides within 

CY 2001 were in the rank of Sergeant or above (including commissioned officers). 

Resulting in increased: 

 - substance abuse 

 - suicidal behavior

 - criminal behavior

 - promiscuity

 - premature marriage 

 - premature parenthood

Resulting in: 

- reduced substance abuse 

- reduced in-discipline indicators

- high morale/self-worth 

- more successful relationships

- overall better fit Soldier 

-

-

 

OUTPUT

Negative Coping Skills Reinforcement

 - social isolation 

 - ignoring problems

 - withdrawn 

 - destructive peer group involvement

 - lack of leadership involvement 

Behavior Positive Coping Skills 

Reinforcement 

 - social support use 

 - continued education 

 - unit involvement 

 - avocations 

Stressors

Current 

Environment INPUT 

INPUT 

Developmental History

Genetic Vulnerability to

Psychiatric Illness 

FIGURE 2

Not all suicidal behavior is preventable, but time invested in the positive behavioral development 

of our Soldiers can yield many benefits, especially for younger Soldiers. 

2-5. Suicide “Triggers” 

Although psychiatric illness or substance abuse contributes to a majority of all suicides, the 

timing of suicide behavior and a significant emotional event, particularly those involving a loss, 

separation or any change in one’s self-esteem and confidence are often linked together.

D-32
A review of Army psychological autopsies reveal that approximately seventy-five percent of all 

Soldiers that commit suicide were experiencing “significant problems” within a personal, intimate 

relationship. In addition, about half had just received or were pending some form of legal action 

(whether civilian or UCMJ). Approximately forty-two percent were experiencing financial 

problems and thirty-four percent were known to be suffering from either drug or alcohol abuse 

problems. Many of the Soldiers that completed suicides were experiencing more than one of 

the problems mentioned above. Leaders must realize that each individual will handle a 

particular life stressor differently. Some will require assistance, which can range from talking 

with a friend, to professional counseling. Ignored, or left without any assistance, the stressor 

can turn into a “life crisis,” which could lead to suicide ideation or behavior. Therefore, all 

leaders should anticipate potential “life crises” and ensure that the individual has the proper 

resources to handle the adversity. This might include appointing a “life-line” buddy to watch 

over the individual until the crisis has passed or referral to the unit chaplain or other professional 

counselors. 

Provided below is a list of potential triggers for suicide. 

• Loss of a loved one to illness or death. 

• Loss of a significant, intimate relationship (divorce, separation, break-up). 

• Loss of a child custody battle. 

• Loss of friendship or social status (social isolation or ostracism). 

• Loss of a job, rank (UCMJ or civilian legal action, separation). 

• Loss of freedom (incarceration). 

• Loss of financial security (pay loss/reduction, gambling debts, bankruptcy). 

• Loss of self-esteem (humiliation, pass over for promotion or schooling).

• Loss of hope or feeling helpless. 

• Loss or change in lifestyle (unwanted PCS, major deployment). 

Obviously, a common theme for all these potential triggers for suicide is associated with some 

form of a loss. 

D-33
2-6. Reasons for Dying 

To the “well adjusted” person, suicide is an irrational act. This attitude however might interfere 

with a person’s ability to promptly intervene if they assume that everyone shares their opinion. 

Some consider suicide a method of ending or escaping from pain or other problems. An 

understanding of the psychodynamics of suicide is crucial for understanding and potentially 

predicting suicidal behavior. Dr. Tondo and Baldessarini in an article in Psychiatry Clinical 

Management,3 explained suicide psychologically “as an excessive reaction arising from intense 

preoccupation with humiliation and disappointment that is driven by punitive and aggressive 

impulses of revenge, spite, or self-sacrifice, wishes to kill and be killed, or yearning for release 

into a better experience through death." 

As previously mentioned, a review of the psychological autopsies revealed that many suicides

occurred during or immediately following a problem with an intimate relationship. Some of these 

suicides could be explained as “death as retaliatory abandonment,” a termed coined by Dr. 

Hendin.8 In these particular cases, the suicide victim attempts to gain an “illusory control over 

the situation in which he was rejected.” By committing suicide, the victim believes that they will 

have the final word by committing the final rejection, thus maintaining “an omnipotent mastery 

through death.” An example could be a person who commits suicide following a loss of an 

intimate relationship where the spouse or significant other initiated the break-up. Here the 

person attempts to regain control over the situation and dictate the final outcome, which is to 

reject life. 

Another potentially common reason for suicide within the Army is “death as a retroflexed 

murder” where according to Hendin, the suicide stemmed from anger and was an indirect 

attempt at revenge against another person. An example could be a Soldier returns from an 

extended deployment and discovers that their spouse is (or was) having an affair. The Soldier’s 

feelings turn into a “murderous rage” which leads to suicide. In this example, suicide represents 

an inability to repress violent behavior, perhaps due to an “overt desire to murder,” and allows 

the “murderous rage” to act out in a violent act against oneself. 

Dr. Hendin also explains suicidal reasoning as “death as self-punishment,” which he notes is 

more frequent in males. In these cases, perceived or actual failure causes “self-hatred” which 

leads to suicide as a form of “self-punishment.” Hendin notes that this reaction is more common 

in men who place extremely “high and rigid” standards for themselves. An example could be a 

Soldier who is pending UCMJ action, or perhaps possible separation from the Army and feels 

that they have failed and whether through humiliation or embarrassment, feels that they don’t 

deserve to live. 

Jobes and Mann9 examined Suicide Status Forms from various counseling centers and 

determined that they could categorize suicidal patient’s reasons for dying and that these 

categories vary with responses. They then listed the most frequent categories or reasons for 

dying which are listed below in descending order beginning with the most frequent. 

• Escape – general. General attitudes of giving up or needing a “rest.” 

• General descriptors of self. References to self such as “I feel awful” or “I’m not 

worth anything.” 

• Others/relationships. References to other people such as “I want to stop hurting 

others” or “retribution.” 

D-34
• Feeling hopeless. Statements referring to hopelessness such as “Things may never 

get better” or “I may never reach my goals.” 

• Escape-pain. Statements about lessening the pain such as “I want to stop the pain.” 

• Feeling alone. Statements that reflect loneliness such as “I don’t want to feel lonely 

anymore.” 

2-7. Suicide Danger Signs 

The list below contains immediate danger signs that suicide behavior is imminent. 

• Talking or hinting about suicide. 

• Formulating a plan to include acquiring the means to kill oneself. 

• Having a desire to die. 

• Obsession with death including listening to sad music or poetry or artwork. 

• Themes of death in letters and notes.

• Finalizing personal affairs. 

• Giving away personal possessions. 

Anyone who recognizes these warning signs must take immediate action. The first step should 

be to talk to the individual, allow them to express their feelings and asked them outright and 

bluntly, “are you considering suicide?” or “are you thinking about killing yourself?” If their 

response is “yes” then immediate life-saving steps are required, such as ensuring the safety of 

the individual, notifying the chain of command or chaplain, calling for emergency services or 

escorting the individual to a mental health officer. 

The most important point to consider is to never ignore any of these suicide danger signs or 

leave the suicidal person alone. After all, you might be the last person with the opportunity to 

intervene. 

 

2-8. Suicide Warning Signs 

The list below contains some warning signs that might precede suicide behavior. Although not 

as serious as the danger signs previously listed, they should not be disregarded and also 

require immediate personal intervention. The list includes: 

• Obvious drop in duty performance. 

• Unkempt personal appearance. 

• Feelings of hopelessness or helplessness.

• Family history of suicide.

• Made previous suicide attempts. 

• Drug or alcohol abuse. 

• Social withdrawal. 

• Loss of interest in hobbies. 

• Loss of interest in sexual activity. 

• Reckless behavior, self-mutilation. 

• Physical health complaints, changes/loss of appetite. 

• Complaints of significant sleep difficulties. 

These signs signal that the person might be experiencing a life-crisis and requires assistance. It

is the responsibility of all leaders and the duty of all Soldiers and civilians to watch for these 

D-35
danger and warning signs and realize that they might not be capable of helping themselves and 

therefore, require immediate action. 

In addition to the warning signs provided above, there are certain feelings or emotions that 

might precede suicide. The following is a list of possible feelings or attitudes that the individual 

at risk for suicide might be feeling. This does not suggest that everyone who has these feelings

are at risk, but these feelings persist, then it could signal that the person is having difficulty 

coping with what ever has initiated the feelings. The most common feelings are: 

• hopelessness or helplessness 

• angry or vindictive 

• guilty or shameful 

• desperation

• loneliness 

• sad or depressed 

Leaders, Soldiers and civilians must be confident that the “life crisis” has resolved itself before 

assuming that the person is no longer suicidal based solely upon the person’s behavior. Some 

individuals might appear to be over their crisis, when in fact, they only appear “normal” because 

of the relief they feel in having decided on how they are going to resolve their problem through 

suicide. 

2-9. Resources for Living. 

Certainly, it is important to understand what causes suicide behavior, but it is also vitally 

important to understand those resources that offer protection against dysfunctional, selfinjurious behavior. Tondo and Baldessarini provide the following list of protective factors 

against suicide. 

• Intact social supports, including marriage. 

• Active religious affiliation or faith. 

• Presence of dependent young children. 

• Ongoing supportive relationship with a caregiver. 

• Absence of depression or substance abuse. 

• Living close to medical and mental health resources. 

• Awareness that suicide is a product of illness, not weakness.

• Proven problem-solving and coping skills. 

Just as important as recognizing reasons for suicidal behaviors are reasons for living. Jobes 

and Mann categorized the top reasons for living in the list provided below (in descending order 

beginning with the most prominent). 

• Family. Any mention of a family member’s love. 

• Future. Statements that express hope for the future. 

• Specific plans and goals. Future oriented plans. 

• Enjoyable things. Activities or objects that are enjoyed. 

• Friends. Any mention of friends. 

• Self. Statements about qualities of self such as “ I don’t want to let myself down.” 

• Responsibilities to others. Any mention of obligations owed to others or the thought 

of protecting others. 

D-36
• Religion. Statements referring to religion. 

Leaders should understand what serves as a source of strength or life-sustaining resource for 

the Soldier and civilian and use them when counseling them through a particular crisis. Also, by

understanding a Soldier or civilian’s life resources will alert the leadership to potential problems 

when one of those resources have been removed or is in danger. 

D-37
Chapter Three – The Army Suicide Prevention Model 

“Knowing is not enough, we must apply. 

Willing is not enough, we must do.” 

Goethe 

The Army Suicide 

Prevention Model INDIVIDUAL 

READINESS 

FIGURE 3 

Continuity 

 

 

Of 

 Care 

Outpatient Care

Training 

Inpatient Care

Follow on Care

Postvention

Referral 

Vigilance 

Awareness 

 

- Identifying “High Risk” Individuals 

- Caring and Proactive Leaders

- Encouraging Help Seeking Behavior

- Positive Life Coping Skills 

Normal Life PREVENT

Stressor 

 or 

Disorder

- Suicide Awareness and Vigilance 

- Integrated & Synchronized Unit and 

Community-wide support Agencies 

- Assured Problem Resolution

INTERVENE

Life 

Crisis

- Safeguard 

- Psychiatric Treatment 

- Psychiatric Assessment

SECURE Suicidal

Ideation

Suicide 

Behaviors

DEATH 

3-1. General Overview 

The Army Suicide Prevention Model focuses on maintaining the individual 

readiness of the Soldier and civilian. Occasionally, through normal life 

experiences, a person enters a path that if followed, and without interruption or 

intervention, could allow a normal life stressor or mental disorder to become a life 

crisis, which might lead to thoughts of suicide and eventually suicidal behavior and 

possible injury or death. Parallel to the suicidal path is a “safety net” that represents the Army’s 

D-38
continuity of care. As the actual suicidal risk escalates, so does our response by becoming 

more directive and involving more professional health care providers. To prevent a person from 

progressing down the suicidal path are three “barriers” which are: prevention, intervention, and 

secure. These barriers target specific programs and initiatives for varying degrees of risk to 

block any further progress along the suicidal path. Provided below is a quick outline of each of 

these “barriers” with more detailed strategies following in Chapters Four, Five, and Six. 

3-1a. Prevent. Prevention is our “main effort” to minimize suicidal behavior. It focuses on 

preventing normal life “stressors” from turning into a life crisis. “Prevention Programming” 

focuses on equipping the Soldier and civilian with the coping skills to handle overwhelming life 

circumstances that can sometimes begin a dangerous journey down a path to possible suicidal 

behaviors. This barrier allows the individual to operate “in the green” or at a high state of 

individual readiness. Prevention includes establishing early screening to establish baseline 

mental health and offer specific remedial programs before the occurrence of possible 

dysfunctional behavior. Prevention is absolutely dependent on caring and proactive small unit 

leaders who make the effort to know their subordinates, including estimating their ability to 

handle stress, and offer a positive, cohesive environment which nurtures and develops positive 

life coping skills. 

3-1b. Intervene. Intervention is the barrier that prevents any life crisis or mental disorder to 

lead to thoughts of suicide. It recognizes that there are times when one should seek

professional assistance/counseling to handle a particular crisis or treat a mental illness. In this 

area, early involvement is a crucial factor in suicide risk reduction. Intervention includes 

alteration of the conditions, which produced the current crisis, treatment of any underlying 

psychiatric disorder(s) that contributed to suicidal thoughts, and follow-up care to assure 

problem resolution. Commanders play an integral part during this phase as it is their

responsibility to ensure that the particular problem or crisis has been resolved before assuming 

that the threat has passed. This barrier is color-coded “yellow” because it warrants caution and 

the individual readiness is not to an optimal level since the individual might be distracted by the 

life crisis. 

3-1c. Secure. The third and final barrier in this model is perhaps the last possible opportunity 

to prevent an act of suicide. This occurs when an individual is at risk for suicidal behavior. 

When someone becomes suicidal, then someone must secure and protect them before they can 

harm themselves and/or others. This is “tertiary prevention” and requires immediate life-saving 

action. The focus within this area will be to educate everyone to recognize those suicidal 

danger and warning signs and if recognized, take immediate, life-saving action. This barrier is 

color-coded “red” due to the severity of the situation. This individual is considering or has 

already decided to commit suicide and is in imminent danger of harming him or herself, or 

possibly others as well. 

3-1d. Continuity of Care. The safety net underneath the suicidal path within the model 

represents the continuity of care that the Army is required and obliged to provide those 

individuals at risk for suicide. It starts with awareness of the impact and magnitude of suicide

within the Army. It continues with training, education, and ensuring constant vigilance of those 

who might be at risk for suicide. As the risks increases, so does the level of required care, 

including referrals to professional gatekeepers and if appropriate, in-patient care until assurance 

of problem resolution. The most intensive care will be required to those who actually commit a 

suicide act, ranging from medical care and psychiatric therapy (for non-fatal suicide acts) to 

bereavement counseling for surviving family members and personal counseling for unit 

members for completed suicides. 

D-39
The Army Suicide Prevention Model is to assist those who have any ambivalence towards 

dying. All leaders should understand that no suicide prevention plan will completely eliminate 

suicidal behavior. Despite our best efforts, there will always be some, whether through their 

genetic predisposition and/or their developmental history, who will be more susceptible to 

suicidal behavior. Some will travel down the path to suicide without ever displaying any 

recognizable danger signs. Some travel down the path very quickly and don’t want any 

intervention. Suicide is an individual decision and therefore, ultimately, the responsibility of the 

individual. However, that doesn’t relinquish our obligation, but only serves as a challenge to be 

vigilant and aware so that we can identify all who are at risk and apply the appropriate level of 

intervention. 

 

 

D-40
Chapter Four – Prevention 

A commander should have a profound understanding of human nature... 

Sir Basil Liddell Hart 

PREVENT 4-1. Identifying “High Risk” Individuals 

This phase begins with pre-screening upon arrival 

for initial entry training (IET) within the Army to 

identify those individuals considered high risk for 

suicidal behavior. Today’s recruits enter the Army 

with varying resiliency levels to handle stress, 

anger and intimate personal relationships. As 

previously discussed, some are predisposed to 

dysfunctional health risk behaviors. Recognizing

that the baseline mental health of our inductees 

may be less than optimum requires proactive 

identification and targeted education/intervention 

and ongoing mentoring by unit leadership. This 

intervention will assist the first term Soldier and 

civilian in avoiding some of the normal pitfalls that

can lead to mental health dysfunction and 

subsequent early attrition. These pitfalls include:

• Identifying “High Risk” Soldiers 

- Pre-screening for Adverse Childhood 

Experiences 

• Caring and Proactive Leaders 

- Understanding Potential “Triggers”

- Sense of Unit Belonging/Cohesion 

• Encouraging Help-Seeking Behavior 

• Teach Positive Life Coping Skills 

- Total Physical, Spiritual, and Mental Health 

- Avoidance of Stress-inducing Behaviors 

TABLE 1 

• Premature marriage 

• Premature parenthood 

• Excessive debt 

• Substance abuse 

• Dysfunctional behaviors resulting in UCMJ 

• Authority difficulties 

• Inability to form positive supportive relationships

• Excessive time demands relative to time management skills 

• Family of origin problems-acute and unresolved from past 

• Dissonance between expectations and reality 

4-2. Caring and Proactive Leaders 

Although our first line of defense will be our Soldiers and civilians,” truly our most valuable 

player in suicide prevention will be the small unit leader or first line supervisor. These leaders 

must recognize that the most important resources entrusted to their care are their Soldiers and 

civilians. Suicide prevention requires active and concerned leaders who express a sincere 

interest in the overall welfare of their subordinates. This includes taking the time to learn as 

much as they can about the personal dynamics of their subordinates. They must be able to 

recognize serious personal problems before they manifest themselves as dangerous 

dysfunctional behavior(s). Leaders should be trained to recognize the basic symptoms of a 

serious mood disorders such as depression and substance abuse. The intent is not to train 

leaders to make a clinical diagnosis, but rather to alert the chain of command of a particular 

concern, so that the commander can make an informed, “pre-emptive” decision to make a 

referral to a professional MHO. In addition, all leaders should be familiar with those stressors 

and potential suicidal “triggers” and know when one of their Soldiers or civilians are 

experiencing a crisis and might be at risk. 

D-41
All leaders should strive to create and foster an environment of acceptance and cohesion for all 

members of their unit or section. No one should ostracize or make any member of a unit feel 

unwelcomed, regardless of their action. Everyone should feel that they are a valuable part of 

the team and that others depend on them. This is especially true when someone is facing a 

problem or potential life crisis, whether personal or professional. 

4-3. Encouraging Help Seeking Behavior 

All leaders should encourage help seeking behavior within their subordinates, without fear of 

repercussions. Many senior Soldiers and civilians fail to seek professional assistance from a 

MHO for fear of reprisals, embarrassment, guilt, or shame. According to a 1998 DoD Survey of 

Health Related Behaviors Among Military Personnel, only 24 percent of Soldiers surveyed 

believed that receiving mental health counseling would not hurt their career. It is therefore easy 

to understand that although 17.8 percent 

of Soldiers feel that they have needed 

mental health counseling in the past, only 

5.6 percent actually sought and received 

help. 

Clearly, for our suicide prevention 

program to be effective, we have to 

reduce the perceived stigma of seeking 

mental health counseling. We can reduce 

the stigma by first ensuring against 

inadvertent discrimination of Soldiers and 

civilians who receive mental health 

counseling, and secondly by supporting 

confidentiality between the individual and 

MHO. Both of these objectives will 

require comprehensive and commandsupported efforts to review policies and 

procedures. 

 ARMY DOD 

Perceived Need for Mental 17.8%

 17.6%

Health Counseling 

Receipt of Mental Health counseling

from military mental health professional 5.6% 5.2%

Perceived Damage to Career 

 Definitely Will 17.7% 20.7% 

 May or May Not 58.1% 59.8%

 Definitely Will Not 24.2% 19.5%

DoD Survey of Health Related Behavior

T

A

Confidentiality in the face of suicide risk must strike a balance between safeguarding the 

individual and/or the public and protecting their privacy rights. In order to enhance the ASPP 

and overall effectiveness of the mental health care services, commanders will respect and 

honor prescribed patient-doctor’s privacy rights as prescribed in DoD Regulations, and 

applicable statutes, including Privacy Act, 5 U.S.C. 552a. Therefore, confidential mental health 

care communications shall, except as provided by DoD Regulations, not be disclosed. 

Exceptions to this general rule include, but are not limited to: 

• when the patient has given their consent, or 

• when the mental health professional believes that a patient’s mental or emotional 

condition makes the patient a danger to himself or herself, or to any other person, or

• when the mental disorder indicates a degree of impairment otherwise suggesting 

unsuitability for retention in military service, or 

• in the case of an adjustment disorder of a military member during the member’s initial 

180 days of military service, or 

• military necessity to ensure the safety and security of military personnel, family 

members, or government property. 

D-42
Therefore, mental health professionals will inform the responsible unit commander when one of 

their Soldiers or civilians is at an elevated risk for suicide, or at risk for other dangerous 

behavior, or if the commander referred the individual. Otherwise, the individual’s privacy takes 

priority and the Army will respect it. 

4-4. Teach Positive Life Coping Skills Development 

Prevention also includes developing the Soldier and civilian’s mental resiliency, emphasizing 

avoiding premature stress-inducing decisions (i.e., as getting married too young, or starting a 

family). It is important for all leaders to recognize that mental wellness is a component of the 

triad of overall individual fitness (physical and spiritual being the other two). 

Positive life coping skills training may include alcohol abuse avoidance, financial management, 

stress and anger reduction, conflict management, and parenting and family life skills such as the 

Building Strong and Ready Families (BSRF) seminar originated within the 25th Infantry Division. 

BSRF offers married couples an opportunity to strengthen their relationship through various 

instruction and exercises. The seminar was targeted for those newly married couples who were 

interested in improving their communication skills and generally being better equipped to handle

the stresses of married life, including child rearing. Programs such as BSRF are a great 

example of how to develop life-coping skills and will indirectly have a positive impact on 

reducing suicidal behavior. 

 

D-43
Chapter Five – Intervention 

The only thing that can save a human life is a human relationship! 

5-1. Suicide Awareness and Vigilance 

This phase deals with individuals who are 

dealing with a particular crisis, that left 

untreated, can lead to suicidal behavior. 

Suicide intervention can involve anyone. The 

strategy of the ASPP is to train everyone in 

basic suicide awareness so they can spot 

someone who is displaying suicidal warning 

or danger signals and know what actions to 

take to protect the person at risk. Leaders 

will ensure that all of their subordinates have 

received this training at some point in their 

career. Conduct refresher training as 

required. 

• Suicide Awareness and Vigilance 

- Targeted Training for Specific Audiences 

• Integrated & Synchronized Unit and 

Community-wide support Agencies 

- Accountability for Prevention Programs 

• Assured Problem Resolution 

I

N

T

5-2. Applied Suicide Intervention Skills Training (ASIST) 

Raising awareness and vigilance will invariably increase the number of “false-positives” or those 

who identified as at risk for suicide, but are not actually considering suicide. These “falsepositives” could overwhelm community mental health resulting in increased workloads and 

longer referral times for those who are actually at risk. To reduce the number of “falsepositives” and to assist the commanders in making an informed determination of suicidal risk, 

will require professional training (such as Living Works Applied Suicide Intervention Training –

ASIST). This training must be easily accessible to the unit commanders, (a minimum of one 

person trained in every battalion). Such training is not just limited to chaplains. During Desert 

Shield and Storm, V Corps units sponsored many ASIST Workshops for unit leadership and 

civilians in preparation for an expected increase in the number of potential ‘at-risk’ individuals. 

Founded as a partnership in 1983, Living Works Education is a public service corporation 

dedicated to providing suicide intervention training for front-line caregivers of all disciplines and 

occupational groups. The Living Works objective is to register qualified trainers in local 

communities, who in turn can prepare front-line gatekeepers with the confidence and 

competence to apply immediate “first-aid” suicide intervention in times of individual and family 

crises. The ASIST workshops include instruction on how to estimate suicidal risk and apply an 

intervention model that reduces the immediate risk of suicide. The purpose of ASIST is not to 

produce personnel qualified to diagnose mental disorders, or to treat suicidal individuals, but 

rather provide the immediate first aid response for those individuals until such time they can be 

referred to a trained, professional mental health care provider. 

 

ASIST “T-2” is a two-day workshop that commanders should offer to all military and civilian 

gatekeepers. Each T-2 course is limited to approximately thirty individuals and requires two 

“T4T” level trainers. 

ASIST T4T’s. Each major installation should have at least two ASIST T4T qualified trainers that 

could conduct the ASIST T-2 workshops on their installations or within their geographical region. 

One of these two should be the installation Family Life Chaplain. Family Life Chaplains work 

closely with allied helping professionals within the installation and local community. In addition, 

D-44
part of their responsibilities include training Chaplains and their assistants assigned to Unit 

Ministry Teams. Family Life Chaplains have also received additional training that would 

enhance the ASIST training and would therefore be excellent candidates to sponsor and 

conduct the training. To become an ASIST “T4T” qualified trainer requires attendance of the 

five day trainers course taught by Living Works Education. 

For every Family Life Chaplain in an installation, there should be an allied helping professional

or mental health professional who will be the ASIST T4T training partner. This could be 

someone within the Family Advocacy Program, another Chaplain assigned to the post or 

installation, the Community Health Nurse, or any professional civilian or military counselor. 

Consider longevity, demeanor, ability (time) to conduct the workshops when deciding who 

should become an ASIST T4T. 

ASIST Workshops. Each installation T4T team must conduct at least three ASIST workshops in 

the first year following the T4T qualification training. Priority candidates for this training are the 

primary and secondary installation gatekeepers as specified in para 5.3c.

For more information on Living Works, visit their web-site (address provided in Annex H). 

5-3. Five Tiered Training Strategy

This training will be specialized, multi-tiered five specific groups, each with different 

responsibilities within ASPP. Figure 4 reflects these. 

Army Suicide Awareness Training Model 

• Tertiary Suicide Prevention 

Advanced Screening Techniques 

Leaders & Supervisors 

Installation 

Gatekeepers 

Unit Ministry, MH & 

 CSC Teams

Mental Health Care 

Providers

• Suicide Risk Identification 

• Available Unit and Community Support 

Agencies

• ASIST Trained 

• Counseling and/or referral 

• Interaction with Chain of 

d

•

• ASIST & Basic Suicide Prevention Trn

• Family Life Advocacy

• Relationship/Life Skill Training

HIGH

Comman • Policy 

• Total Individual Well-being 

• Encouraging help seeking behavior

LOW 

Specificity FIGURE 4

All Soldiers & Civilians 

5-3a. Soldiers & Army Employees. All Army Soldiers and civilian employees shall receive 

basic training stressing the importance of mental health, stress reduction, and life coping skills. 

D-45
They will also learn how to recognize suicide behavior and mental disorders that place 

individuals at elevated risk of suicide and how to react when they spot these issues. Most 

suicidal individuals give definite warnings of their suicidal intentions, but others are either 

unaware of the significance of these warnings or do not know how to respond to them. All 

Soldiers and civilians should receive training on how to properly identify these warning signs 

and know what action to take. 

They must realize they may be the only and/or last hope to save a fellow Soldier or civilian. 

Many psychological autopsies reveal that those who committed suicide had told one of more of 

their fellow peers, but they did not believe the individual was serious or were embarrassed or 

afraid to intervene. Army units should turn to either their Unit Ministry Team, brigade or division 

mental health, combat stress control unit on post, or local mental health section for qualified 

instructors. Civilian supervisors should arrange training directly through the Installation 

Chaplains Office or local mental health department. 

Unit commanders should also encourage suicide prevention training to all spouses through the 

Family Readiness Groups or other unit or installation spouse education/familiarization education 

classes/programs. 

5-3b. Leadership Training. All Army leaders shall receive training on the current Army policy 

toward suicide prevention, how to refer their subordinates to the appropriate helping agency, 

and how to create an atmosphere within their commands of encouraging help-seeking behavior. 

Civilian supervisors will also receive training that focuses on referral techniques/protocols for 

their employees. 

 

5-3c. Installation Gatekeepers. Installation gatekeepers, those individuals who in the 

performance of their assigned duties and responsibilities provide specific counseling to Soldiers 

and civilians in need, will receive training in recognizing and helping individuals with suiciderelated symptoms or issues. Gatekeepers can be identified as either a “primary gatekeeper” 

(those whose primary duties involve primarily assisting those in need and more susceptible to 

suicide ideation) and “secondary gatekeepers” (those whose might have a secondary 

opportunity to come in contact with a person at risk). The table below describes examples of 

each. 

Primary Gatekeepers Secondary Gatekeepers

Chaplains & Chaplain Assistants Military Police 

 ADAPCP Counselors Trial Defense Lawyers 

Family Advocacy Program workers Youth Services 

 AER Counselors Inspector General Office 

Emergency room medical technicians DoD School Counselors 

 Medical Health Professionals MWR Workers 

 Red Cross Workers

 

5-3d. Unit Ministry Teams. Chaplains and their assistants belonging to each Unit Ministry 

Team will assume the lead in providing suicide prevention and awareness training for their 

respective units. All chaplains and assistants will therefore receive basic suicide 

prevention/awareness and ASIST T-2 Training as determined by the Chief of Chaplains. 

Utilizing the USACHPPM’s resource manual as a guide, each UMT should develop lesson plans 

to provide the suicide prevention/awareness training to all ranks at the platoon and company 

level, and NCOPD and OPDs at the battalion level. 

D-46
5-3e. Combat Stress Control Teams. The 85th Medical Detachment, Combat Stress Control,

following the example first set by the Medical Activity and 1st Cavalry Division in the 1980s, 

conducts a “Combat Stress Fitness Course” once or twice a month at Fort Hood for Soldiers 

referred directly from their units or by way of the mental health clinics. For five duty days, the 

students participate in classes and practical exercises on stress management, anger 

management and other life skills, taught by the CSC unit mental health officers and enlisted 

specialists in a military, not patient care, atmosphere. Finishing the course earns a certificate of 

completion which has positive value for advancement. Graduates of the course who entered as 

candidates for chapter separation from the Army have returned months later as Soldiers of the 

quarter, to inspire the new class. The 98th CSC Detachment at Fort Lewis periodically conducts 

a similar program, both in garrison and in the field during field exercises. At Fort Bragg, the 

528th CSC Detachment provides “train the trainer” courses to prepare unit leaders to give their 

own classes to the troops, including stress control and suicide prevention. 

5-3f. Mental Health Professionals. Mental Health Care Professionals will develop advanced 

screening techniques that the command can use to identify Soldiers and civilians in need of 

assistance with coping skills development and or who are potentially high risk for suicides. 

Mental health professionals, working with the Unit Ministry Teams, are required to actively 

educate leaders in suicide prevention and awareness. 

5-4. USACHPPM Suicide Prevention Resource Manual 

US Army Center for Health Promotion and Preventive Medicine has developed an excellent 

Suicide Resource Training Manual complete with lesson plans and slides. All units should use 

this resource manual in the preparation and execution of their suicide prevention training. An 

electronic version of this manual is available on the USACHPPM’s web site (address provided in 

Annex H). 

5-5. Integration and Synchronization – The Installation Suicide Prevention Committee 

To integrate the available “pool of resources” within an installation and local community and 

synchronize these resources throughout the individual unit suicide prevention programs require 

a central controlling agency. This responsibility should fall to some form of a standing

committee on each major installation and separate activity. This committee’s main 

responsibilities are to establish, plan, implement, and manage the installation ASPP. It will 

maximize and focus available resources and ensure that the local unit ASPPs are “nested” 

within the overall installation plan. 

In the Surgeon General’s Call to Action, the Surgeon General places much emphasis on 

increasing awareness and enhancing intervention services at the community level. It is 

important that whatever the form of the local program, responsibilities must be clearly 

established and the installation commander closely monitors and supervises the progress of 

their specific suicide prevention program. 

The intent of establishing an Installation Suicide Prevention Committee is to focus installation

and community assets towards assisting in suicide awareness and prevention. Involvement of 

local agencies and unit training will have a synergistic affect, which will result in minimizing 

suicidal behavior. Although the exact composition will depend on the specific local 

requirements, the garrison or installation commander should chair the standing committee and 

might involve representatives from the agencies listed below. Members could serve as either 

permanent or “ad hoc” members as the situation dictates. 

D-47
Chair: Installation or Garrison Commander 

Possible Members: 

-ACS -Trial Defense/SJA -Family Advocacy -PAO 

-Provost Marshal -CID -Dept of Psychiatry -AAFES 

-Post Chaplain -MWR -Dept of Psychology -ADAPCP 

-CPAC -Youth Services -DOD Schools -IG 

-Safety -Dental -Red Cross 

-Dept of Social Services 

In addition to determining the exact membership of the committee, it is the installation

commander’s prerogative to determine how often the committee will meet or if the committee’s 

responsibilities are included within another previously established installation committee, such 

as an installation risk/injury reduction committee. The actual name, composition and activities 

of the committee are at the discretion of the installation commander. If the commander 

determines that the size, location, or composition of the installation wouldn’t sufficiently support 

such a committee, then that particular commander will coordinate with another installation 

commander for inclusion within their suicide prevention committee. 

The ISPC should form subcommittees that meet on a more frequent basis. Subcommittees 

might include those responsible for monitoring training and preparing reports to HQDA, another 

might focus on postvention suicide reaction and would be responsible for preparing or reviewing 

the suicidal surveillance reports, and dispatching a critical event response team that would 

facilitate the healing process, provide assistance in arranging unit memorials, and prevent 

possible contagion or “copy cat” suicides. Another subcommittee might focus on the 

education/training of suicide prevention at the installation level. 

Another important function of the ISPC will be to link installation agencies through a 

communications network that can share crucial information on potential suicidal Soldiers. At a 

minimum, this will include the Family Life Chaplain, family advocacy, SJA, CID, ADACP, Red 

Cross, Financial Counselors and social services. These links should feed into the local Army 

mental health council for consolidation and if warranted, notifying the individual’s appropriate 

commander of the potential suicidal risk. 

For detailed recommendations on establishing an installation suicide prevention standing 

committee, refer to Chapter 2, DA PAM 600-24, Suicide Prevention and Psychological Autopsy, 

30 September 1988. Army divisions and other large activities with adequate support interested 

in considering establishing their own suicide prevention program (previously referred to Suicide 

Risk Management Teams) should refer to Chapter 3, DA PAM 600-24. This is available on-line 

at the Army Administrative Electronic Publication website at www.usapa.army.mil/gils/

5-6. Commander’s Involvement/Responsibilities 

Unit commanders are accountable for their suicide prevention programs. This includes ensuring 

the proper training of unit personnel and ensuring that all leaders are actively engaged in the 

personal welfare of their Soldiers. 

Once a Soldier or civilian experiencing a “life crisis,” is identified, it is the responsibility of the 

commander to ensure that that individual not only receives the proper crisis intervention, but 

that the problem has been fully resolved. The referral doesn’t end the commander’s 

intervention responsibility, but only initiates the involvement which continues until the

D-48
commander is completely assured that the particular crisis or disorder has been resolved. This 

includes properly safeguarding the person at risk while they are receiving the required,

professional assistance from mental health care providers. 

BH professionals that are treating individuals at risk for suicide should keep the commander 

informed, as well as making recommendations for safeguarding the individual during the 

treatment, (if the treatment is outpatient care). Clear and expedient communications flow is 

crucial between those who are treating the individual at risk and the individual’s commander to 

ensure disclosure of all appropriate information to enable an accurate diagnosis. 

D-49
Chapter Six – Secure 

6-1. Safeguard SECURE 

This is perhaps our last opportunity to successfully prevent 

the individual from taking his or her life. At this point, the 

individual is now considering suicide and is in immediate 

danger for self-injurious behavior. If any Soldier or civilian 

ever hears another person mention that they are 

considering suicide, or make any statements of an intention 

to die, such as, “I wish I were dead,” or are displaying any 

of the suicide danger signs as contained in paragraph 2-7 

and warning signs as contained in paragraph 2-8, then it is 

their responsibility and moral obligation to act. 

Safeguard 

Psychiatric Treatment 

Psychiatric Assessment 

- Rehabilitate vs. Separate

TABLE 4 

If you suspect someone might be at risk for suicidal behavior, then the first step is to ensure the 

safety of the individual at risk. Talk to the individual, and listen. Ask the individual if they are 

considering suicide or “killing themselves.” If their response is “yes,” then ask if they have 

thought about how they would carry it out (a plan) and then determine if they have the 

resources to carry out the plan. This will enable you to determine the actual risk and will be 

useful information for the professional mental health care provider. If you believe the individual 

is at risk for suicide, then you must contact someone within the chain of command, a chaplain or 

UMT member, or the local medical treatment facility. Depending on the severity of the situation, 

you may have to contact the local emergency services including the military police. The main 

point to remember is to remain calm and don’t panic and never leave the person at risk 

unattended. 

Safeguarding for Soldiers might include assigning a 24-hour watch over the individual until 

transfer of the individual to a local medical treatment facility or the risk has subsided. Also, if the

commander feels that the individual is at risk for self-injurious behavior or is a potential danger 

to others, restrict the Soldier to the unit area. If a Soldier is determined to be at risk for suicide, 

and is placed on suicide watch, then other members within the unit must also be aware so that 

they unknowingly will not provide a method or means for the Soldier to commit suicide. 

Commanders must also ensure that the Soldier at risk does not have access to any means to 

commit suicide, which should include denying access to firearms, poisons, over-the-counter 

medications, alcohol, high places, rope, etc. 

Commanders must realize that actions taken to protect a person or the public from potential 

harm, while shielding the at-risk person from public humiliation, takes precedence over any 

other possible concern. 

6-2. Behavioral Health Treatment 

Ultimately, a professional mental health care provider at the local medical treatment facility will 

receive referrals for all individuals at risk for suicide. The professional mental health care 

provider will then determine or verify the actual risk and decide upon outpatient treatment or 

hospitalization. 

6-3. Behavioral Health Assessment 

Once admittance of a person to a hospital, it is the responsibility of the MHO to make an 

assessment the severity of the problem and a diagnosis on possible treatment and prognosis for 

recovery. The MHO will make every effort to successfully rehabilitate the person and return 

D-50
them to duty. When appropriate, commanders should consider reassigning the person to 

another unit if in the opinion of the attending MHO and unit leadership that it would be beneficial 

to the person. Retain the person if successfully be rehabilitated. Mental health professionals 

will recommend initiation of separation procedures (medical or administrative) to the chain of 

command, if they assess unsuccessful rehabilitation of the person. In the case of separations, 

the mental health professional should recommend procedures to the commander for 

safeguarding the individual during the discharge, including whether or not the person is released

back to his unit considering the impact on unit morale, readiness and possible contagion effects. 

The command will then make all efforts to prepare the person for the transition, with the priority 

on the individual’s welfare. 

D-51
Chapter Seven – Post-intervention Measures

It would be unrealistic to expect that any suicide prevention program will ever completely 

eliminate suicidal behavior. Despite our best efforts, there will always be some suicidal 

behavior that is unpreventable. In the event of a completed suicide, our efforts must focus on 

postvention strategies that expedite the healing process of surviving family members and 

members within the unit. Commanders must be aware of the potential danger of suicide 

contagion or “copy cat” behavior by other members within the command or, depending on the 

publicity of the suicide, within the installation. 

7-1. Installation Suicide Response Team 

The immediate time-period following a completed suicide can be very perilous as some

members within the unit may feel some responsibility for the suicide and the possibility of 

suicide contagion also looms. Yet few company and even battalion level commanders have 

ever experienced a completed suicide within their units. To offset the risk, each major 

installation will establish policies and programs that offer immediate assistance to the 

commander following a completed suicide. This will include identifying members of an 

Installation Suicide Response Team (ISRT) that can offer assistance to the unit commander and 

or surviving members of a completed suicide. The membership of the ISRT will be determined 

by each ISPC, but at a minimum should include chaplains that can augment the UMT and help 

advise the commander regarding memorial services, and MHOs that can offer counseling and 

recommend procedures to expedite the recovery within the command. The goal of the ISRT 

isn’t to replace the unit leadership or determine fault, but rather to advise and offer assistance. 

7-2. Completed Suicide Reporting Procedures

IAW AR 600-63 & DA PAM 600-24, a psychological autopsy was required for all confirmed or 

suspected suicides, or those cases in which the manner of death is equivocal, or deaths 

resulting in accidents that are suspicious or when requested by the local USACIDC office. The 

purpose of the psychological autopsy was two-fold, to: 

• provide the victim’s commander with information about the death 

• enable the Army to develop future prevention programs based upon lessons learned 

However, the use of psychological autopsies has grown beyond its original function and now 

serves to promote the epidemiological study of suicide in the Army population. This is against 

the current DoD guidance which limits psychological autopsies for just those equivocal deaths 

or when ordered by either the medical examiner or the local USACIDC office. Therefore, a new 

multi-tiered reporting system will serve to provide the epidemiological study of suicide 

demographics, plus address any concerns or issues that the commander(s) might have 

concerning a confirmed or suspected suicide or determine the manner of the death. The three 

tiers of reporting are: 

 

• Tier One - Army Completed Suicide Surveillance Report (CSSR) 

• Tier Two - Army Suicide Analysis Report (SAR) 

• Tier Three - Army Psychological Autopsy (PA) 

7.2.a. Department of the Army Completed Suicide Report (CSR): 

The purpose of the CSSR will be to capture the epidemiological data regarding the Army suicide 

population. Beginning 1 January 2003, the CSR will be mandatory following every confirmed or 

D-52
suspected suicide of active duty Soldiers, including ARNG and USAR Soldier serving on active 

duty at the time of death. 

The purpose of the CSR is not to assign blame. While understanding that determining any 

lessons learned is valuable, commanders should not take a “fault finding approach” to

investigating suicides or suicide attempts, which would only serve to prolong the recovery period 

for the unit. 

The CSR will be prepared by a MH professional, assigned by the local MEDCOM commander. 

7.2.b. Army Suicide Analysis Report (SAR): 

Completed by a trained MHO appointed by the local installation Director of Health Services 

(usually the hospital commander) after receiving a formal request from either from CID or 

victim's brigade commander or higher echelon commander at that installation. The SAR allows 

the commander an opportunity to present any concerns or questions regarding the death of a 

Soldier or civilian to a professionally trained MHO. Any request for information would have a 30 

day suspense for completion. This report would include the CSSR and additionally provide: 

1) a narrative analysis which details both the developmental/historical events that 

predisposed the victim to suicide as well as a narrative description of the more current 

preceding antecedent precipitants. 

2) a "lessons-learned" & recommendations section. 

3) address any specific questions posed by the chain of command. 

7.2.c. Army Psychological Autopsy (PA): 

Completed only by a fellowship-trained forensic psychiatrist/psychologist. Initiated only at the 

request of the involved medical examiner doing the physical autopsy or CID investigator to 

resolve cases where there is an equivocal cause of death. 

 

D-53
Annex A – Strategy Matrixes 

OBJECTIVE KEY ACTIONS 

Instruct the “Understanding Dysfunctional Behavior Model” (as 

provided in Chapter 3) to officers and NCO’s assigned to leadership 

positions

1. Local MHO’s develop a standardized briefing for ISPC’s 

approval 

2. ISPC’s publishes briefing on local web site or announces POC 

for scheduling the briefing 

3. Local commanders coordinate with local MHOs and conduct the 

training

Encourage and support various life coping skills programs 1. Identify pre-existing and emerging programs that focus on 

developing individual life coping skills such as: stress reduction, 

relationship building, financial management, preventing alcohol 

abuse 

2. Ensure that these programs are publicized and promoted

throughout the installation and made available to Soldiers (both 

active, reserves and retired), family members and Army civilian 

employees 

3. Evaluate successfulness of such programs. Share 

recommendations for improvements or information concerning

new programs to HQDA for dissemination to other MACOMs &

installations 

Build life resiliencies for those who respond to, counsel or treat 

suicidal patients or those exposed to suicides

Develop services and programs, including training and education 

tailored for those who respond to suicides (emergency medical 

technicians, MP’s, firefighters) or counsel those at risk (chaplains, 

counselors) that addresses their own exposure and potential risk. 

Include training/instruction on the unique requirements of

providing initial assistance/counseling to surviving family

members. 

STRATEGY 1: Develop Positive Life Coping Skills 

D-54
STRATEGY 2: Encouraging Help Seeking Behavior

OBJECTIVE 

KEY ACTIONS 

Eliminate any policy which inadvertently discriminates, punishes or 

discourages a Soldier from receiving mental health care 

All staffs and commands will conduct a complete policy review to 

identify any repercussions taken against Soldiers for receiving 

mental health care. Validate those policies that should remain, 

eliminate those that are unwarranted. 

Educate commanders concerning confidentiality requirements as 

determined in objective 2.1 above 

Incorporate policy instruction in all PCC courses, including local 

installation company commander and 1SG Courses pre-command 

courses 

 

Ensure prompt and easy accessibility of Army and other helping 

agencies 

1. Educate Soldiers, family members, Army civilian employees 

and retirees residing in the local community of the location and

protocols for scheduling and receiving assistance from the 

available varying helping services (i.e., AER, American Red Cross, 

MH care) 

2. Incorporate education within installation in-processing 

procedures 

Foster a command climate that emphasizes help seeking behavior Periodic messages, announcements or statements from the senior 

leadership that encourages and recognizes help seeking behavior

as a sign of individual strength and maturity 

Reduce the perceived stigma associated with receiving MH care Sponsor local programs that change perception toward mental

care services. Programs should include adopting national 

programs, public service announcements and developing 

localized, targeted programs that involve varying media sources 

Increase visibility and accessibility to local civilian health and/or 

social services outreach program that incorporate mental health

services and suicide prevention

1. Coordinate with local civilian health and social services to 

identify which services and programs are available to Soldiers and 

family members at risk for suicide. 

2. Develop promotional campaigns to publicize such services to 

Soldiers, Army civilian employees and family members 

D-55
OBJECTIVE KEY ACTIONS 

Render assistance to those known or suspected of experiencing a 

major life crisis

1. Develop systems that recognize when Soldiers and civilian 

employees are experiencing a potential life crisis in an effort to

anticipate potential dysfunctional behavior. 

2. Develop programs that can provide varying levels of

supervision to Soldiers recognized as experiencing a potential 

life crisis. Such programs can vary between assigning a “battle 

buddy” to help the individual through the crisis, to suicide watch 

if the individual has actual suicide ideations 

Educate all Soldiers and Army civilian employees on basic suicide 

prevention, which at a minimum, will cover recognizing warning and 

danger signs and what action to take if they suspect someone is at risk 

for suicide 

1. Utilizing the USACHPPM Resource Manual on Suicide 

Prevention as a guide, educate all Soldiers and Army civilian 

employees on basic suicide prevention. Although not 

mandatory, offer such training to family members. 

2. Ensure newly assigned Soldiers and Army civilian employees 

have previously received the basic suicide prevention education. 

If not, provide training within 60 days upon reporting date. 

3. Incorporate basic suicide prevention in all IET training and 

OBC courses 

Instruct all NCO’s, officers and Army civilian supervisors on 

recognizing symptoms of mental health disorder and potential 

“triggers” or causes of dysfunctional behavior 

1. Instruction will focus on educating leadership on the common 

symptoms of depression, substance abuse or other forms of 

mental disorder

2. Incorporate formal education on 3.2 at all basic leadership 

courses (OBS, PLDC) 

Maintain Vigilance toward suicide prevention and awareness As required, conduct periodic “refresher” training or discussions 

on suicide prevention in preparation for an upcoming extended

deployment or redeployment, or another highly stressful event,

or as designated by commanders. Maintain vigilance by either 

formal training including presentations, small unit discussions or 

even through varying local and Army wide news services and 

media formats. ISPC can also promote various national 

programs such as National Suicide Prevention Week (normally in 

May) and National Mental Health Month (normally in October). 

Educate married Soldiers and Army civilian employees on how to 

appropriately store and secure lethal means of self-harm 

Conduct public information campaign(s) or instruction designed 

to educate Army parents how to appropriately store and secure

lethal means of self-harm including medications, poisons and 

firearms 

Educate all Army health care providers in suicide risk surveillance Educate all health care providers to identify potential suicidal 

danger and warning signs and what actions to take if they

suspect one of their patients to be at risk 

Educate installation gatekeepers on recognizing behavioral patterns 

that place individuals at risk for suicide and equip them with effective 

intervention skills to effectively reduce the immediate risk

Train and maintain at least 90% of all “primary gatekeepers” (as 

defined in para 6-3c) in ASIST (or similar professional training). 

Train and maintain at least 50% of all “secondary gatekeepers”

(as defined in para 6-3c) in ASIST (or similar professional 

training) 

Educate all UMT and Family Life Chaplains suicide awareness and 

prevention

Provide formal basic and advanced suicide prevention training

for all UMT members. Training will include recognizing potential 

danger and warning signs, suicidal risk estimation, 

confidentiality requirements, how to reduce the immediate risk of 

suicide and how to conduct various suicide prevention training at 

the unit level 

STRATEGY 3: Raising Awareness and Vigilance Towards Suicide Prevention

D-56
Educate Soldiers, Army civilian employees and spouses on the safe 

storage of privately owned firearms 

1. Determine which Soldiers within a command has a privately

owned firearm. 

2. Ensure those Soldiers and Army civilian employees and their 

spouses that own personal firearms understand the importance 

of responsible firearm storage in preventing suicide and 

accidental homicide. 

3. Ensure Soldiers seeking permission to purchase a firearm are 

not at risk for suicidal behavior or other dangerous behavior. 

4. Encourage those Soldiers who own personal firearms stored

off-post and are determined to be at risk for suicidal behavior or a 

danger to someone else, to store their weapon in the unit arms

room or with a close friend until the crises has been resolved and 

the risk of suicide has been eliminated. 

Incorporate screening in medical treatment facilities Incorporate screening for depression, substance abuse and 

suicide risk as a minimum standard of care for assessment in 

primary care settings for all MEDCOM supported healthcare 

programs – as part of the clinical practice guidelines initiative

being implemented in the AMEDD 

D-57
STRATEGY 4: Synchronizing, Integrating and Managing the Suicide Prevention Program

OBJECTIVE 

KEY ACTIONS 

Synchronize and integrate local community and installation suicide 

prevention programs 

1. Each ISPC will develop its own charter, which addresses 

formal and “ad hoc” membership of the committee. 

2. Each ISPC will develop and publish its own suicide 

prevention program plan. Forward a copy through the 

respective MACOM HQ to DAPE-HR-PR (ODCSPER) 

Reduce risk of contagion, provide counseling to surviving family members 

and expedite the unit personnel recovery

Establish policies and procedures for the implementation of 

an Installation Suicide Response Team 

D-58
STRATEGY 5: Conduct Suicide Surveillance, Analysis and Reporting

OBJECTIVE KEY ACTIONS 

Capture data on the number of non-fatal suicide events such as attempts 

and gestures 

1. Determine pertinent data fields and 

develop the actual reporting format and procedures. Ensure 

format and procedures do not violate Federal, State or DoD 

regulatory or directives 

2. Implement reporting procedures 

3. Include statistics in monthly suicide surveillance update. 

Provide information to DCSPER and post information on the 

Army Suicide Prevention Web Site 

Conduct suicide surveillance in all Army MTF emergency rooms Ensure that health care providers that work in Army MTF 

emergency rooms receive proper training in identifying 

those individuals whose injuries might have been selfinflicted 

Increase percentage of Soldiers keeping follow-up mental health

appointments 

Establish procedures and guidelines that ensure Soldiers 

keep their mental health care appointments, especially when 

considered at risk for suicide 

Identify and share effective suicide prevention programs Identify those proven programs and initiatives effective in

reducing the risk of suicide and share those programs and 

initiatives with the various MACOMs. Programs will range 

from the installation level to MACOMs and also include 

“best-science methodology” as determined by the Surgeon 

General or other branches of the service. 

Assess availability of mental health and substance abuse treatment

services for youth and DoD Schools 

Assess availability of mental health and substance abuse 

treatment services for youth to determined the need for 

school-based clinical services for DoD schools

Improve reporting of suicidal behavior in news media 1. All Army news services/media divisions will adopt 

recommendations/guidelines concerning reporting suicides 

as provided by the 1989 Health Resources and Services

Administration workshop sponsored by the New Jersey

Department of Health, or AAS, NIMH, CDC, or other 

established suicide prevention organization. The design of 

these recommendations is not to restrict the reporting of 

suicides, but change the manner in which the suicide is

reported. These recommendations will minimize suicide 

contagion. 

2. Installation PAOs should be familiar with such guidelines 

and recommend that local news media adopt such 

guidelines when reporting about suicides within the 

installation or local community. 

D-59
Annex B - Checklists 

 The following checklists serve as a guide that will assist commanders in developing their own 

specific suicide prevention program. 

All Soldiers.

As the first line of defense and perhaps the most important person in suicide prevention: 

9 Know suicidal danger & warning signs and the leading causes for suicides. Remain vigilant! 

9 Take immediate action when suspecting someone is suicidal or if someone admits that they 

are contemplating suicide. 

9 Become aware of local helping services and protocols for use. 

First Line Supervisors/Leaders. 

9 Get to know your Soldiers so that you can recognize and even anticipate possible

dysfunctional behavior. 

9 Assess each of your Soldier’s life-coping skills. Seek opportunities to positively influence 

your Soldier’s behavior. 

9 Ensure proper training of all your Soldiers in suicide prevention/awareness. 

9 Create an atmosphere of inclusion for all. Never ostracize any of your Soldiers, regardless 

of their actions. 

9 Know potential triggers for suicide. 

9 Know potential warning signs for mental illness. 

9 Set the example, take advantage of available helping services. 

9 Reduce the perceived stigma regarding mental health. Remember that most mental 

illnesses are treatable and are a result of a sickness, not weakness. 

Commanders

9 Maintain vigilance. Ensure that members of your UMTs have knowledge of possible life 

crisis or pending UCMJ actions. 

9 Offer suicide prevention/awareness training for all spouses. 

9 Ensure all newly assigned Soldiers are aware of the location and protocols for utilizing 

installation support agencies. 

9 Conduct OPD/NCOPDs for your units that focuses on some aspect of mental illness such as 

recognizing potential warning signs. 

9 Ensure that your UMTs have received formal suicide prevention training currently conducted 

at the Menninger Clinic and have also undergone the Living Works Applied Suicide 

Intervention Skills Training (ASIST) Workshop. 

9 Promote help-seeking behavior as a sign of strength. Working with the mental health 

provider, respect solder/counselor confidentiality when the Soldier’s mental health is not in 

question and when the Soldier is not a threat to himself, not a threat to others, or if they are 

able to perform their prescribed duties. 

9 Develop well-defined procedures for registering and storing privately own weapons. Ensure 

procedures are in place that deny access to firearms during times of suicidal watch. 

9 Ensure any Guard or Reservists attached to your unit for deployment have received proper 

suicidal prevention training and screening prior to deployment. 

9 Ensure there are “family reunion” seminars for both Soldiers and family members to assist in 

the successful integration of the Soldier back into his family following an extended 

deployment. 

D-60
Unit Ministry Teams (UMTs)

9 Become ASIST T-2 trained 

9 Attend formal suicide prevention/awareness training hosted by the Chief of Chaplains

(currently hosted by the Menninger Clinic in Topeka, Kansas) 

9 Download the USACHPPM Resource Manual for Suicide Prevention. Prepare suicide 

prevention/awareness training for “all ranks,” OPDs and NCOPDs and spouses. 

9 Keep your commander informed on current suicide demographics. Explain those identified 

as “high” risk categories – such as those who are experiencing relationship problems, 

financial difficulties or pending UCMJ or other legal action. 

Installation Suicide Prevention Standing Committee

9 Establish suicide prevention program specifically tailored for your installation. 

9 Assist the installation and local commanders in implementing their preventative programs. 

9 Ensure that suicide prevention policies and procedures comply with applicable laws, 

regulations and directives regarding privacy and public information. 

9 Track the percentage of all assigned chaplains that have received the suicide prevention 

basic training at the Menninger Clinic. 

9 Ensure that all assigned commanders and senior NCOs are familiar with the availability of 

support agencies and the procedures for referral. 

9 Ensure that the availability of mental health personnel is adequate to meet the needs of the 

installation and that there is always someone available to conduct crisis 

intervention/assessment. 

9 Ensure that commanders are provided timely feedback from support agencies concerning 

the effectiveness of the treatment of their Soldiers. 

9 Encourage stress management programs for Soldiers and family members, especially 

during times of increased OPTEMPO or deployments. 

9 Track the number of ASIST T-4 (Trainer) and T-2 Level Crisis Intervention trained personnel 

on post. 

• Strive for at least two T-4 qualified trainers that can sponsor the T-2 level training. 

One of the two should be the Family Life Chaplain. 

• Strive for at least one ASIST T-2 trained personnel at each community support 

agency, SJA ,and MPs.

9 Review and publicize emergency procedures available to all Soldiers and family members 

such as Crisis Hotlines and suicide awareness cards. 

9 Ensure newly assigned Soldiers are briefed on installation support agencies during inprocessing.

9 Are dependent school personnel trained in identifying and referring individuals at risk for 

suicide? 

9 Review surveillance reports and monitor the time that it takes to get Soldiers into ADAPCP 

after identification of having an alcohol/drug problem. 

9 Establish procedures for creating an Installation Suicide Response Team 

D-61
D-62

 Annex C – Suicide Risk Comparison of Age Cohorts 

Almost half of all suicides within the Army occur with Soldiers 25 years of age or younger. 

However, maturity doesn’t necessarily protect against suicidal behavior. In fact, older Soldiers 

have a higher suicide rate than younger Soldiers. As can be seen on Graph 1, although the 

greater incidence of suicides within the Army occur in younger Soldiers (represented by the 

dashed line), the highest suicide rates occur in Soldier over 40 (represented by the solid line). 

Army Suicide Ages 

0

5

10

15

20

25

30

35

17-19 20-24 25-29 30-34 35-39 40-44 45+

Total Numbers Rate Per 100k

Age Categories 

GRAPH 1 

By examining psychological 

autopsies, we find that 

younger Soldiers are generally 

committing suicide as a result 

from insufficient or 

underdeveloped life coping 

skills. Suicides among older 

Soldiers reveal a different 

profile of causes. These 

suicides often result from one 

or more clinical psychiatric 

disorders with associated

problems that have 

accumulated over time. Many 

are facing a major life transition, 

such as a failed marriage or a 

promotion pass over. Others 

suffer from chronic substance 

abuse or a mood disorder. 

Unfortunately, many of these 

Soldiers don’t seek professional help, in part because of the perceived cultural and organization 

stigma associated with receiving mental health treatment. 

To prevent both types of suicides requires two different, specific prevention strategies. 

Awareness training can generally prevent preplanned suicides as those who are planning their 

deaths usually give “warning: or “danger” signs that other, vigilant people should intercept. This 

strategy is contained in Chapter Six – Intervention. 

Those unplanned, impulsive suicides are more challenging to prevent since the time from the 

decision, to the suicide act might be quick and not long enough for the potential suicide victim to 

display any warning signs. To prevent these types of suicide requires programs that prevent the 

individual from ever considering suicide as a viable option, which means developing their life 

coping skills so that when faced with a particular stressor, they will have the means to handle it 

without it turning into a crisis and potential suicide. This strategy is contained in Chapter Five – 

Prevention. 
Younger Age Group Older Age Group 

Impulsive, lacks coping skills MDD (Major Depression) or serious heavy ETOH (alcohol) use

Poor adjustment to military settings Good previous adjustment to Army

Situational stressor Major loss or transition issue 

Suicidal behavior happens with little forethought Contemplating suicide for some time as part of a biological disease 

process 

Immature Mature person whose biology or complicated past (or often both) has

caught up to him 

Engages in acting out behavior that is often hard for 

superiors to miss 

Quietly withdraws from those who might notice; behavior of social 

withdrawal and his accompanying internal feelings of shame are easy

to miss 

First term of enlistment—not that concerned about career 

impact

Career Soldier; concerned that MH contact will be seen as weakness 

and will hurt his career 

Will often confide to anyone who is interested Shame, a symptom of MDD and often of ETOH dependence, makes it 

difficult to tell anyone and magnifies fears about “the Army” finding out 

Often lives in barracks and eats in dining facility; used to 

superiors being aware of details of his “personal life” 

Lives in housing or off base; has erected certain barriers between his 

duty day and his personal life 

Assurances of confidentiality and assurances that getting treatment for 

a MH problem is not career damaging (stigma) become very important

in combating the shame (which is part of the biological disease 

process) and thus allowing the Soldier to feel it is “safe” to come 

forward and get help. 

 It is important that these beliefs are in place before the Soldier gets 

depressed (thus the importance of this campaign which promotes both 

a culture change from above and a training component which gets the 

word out below). Once the Soldier is clinically depressed the 

symptoms of shame and social withdrawal make it very difficult to 

reach him. 

Usually a facilitating “gatekeeper” helps him get to MH 

(chain of command or others) 

Usually self referred to MH; may have conferred with a colleague; tends 

to tell chain of command as a last resort or not at all 

Goes to MH with little thought of negative ramifications if

directed or suggested by chain of command 

Has viewed MH as a place where problem Soldiers go—often to

facilitate separation from the service 

Early intervention may prevent acting out behavior and may

facilitate development of more mature coping skills 

Early intervention prevents progression from mild depression to 

serious biological depression; both depression and early alcohol 

dependence, particularly in those who have previously made a good 

occupational and social adjustment; are usually very responsive to 

treatment

Command is already aware of the problem since MH contact 

was either command directed or encouraged by a member 

of chain of command—a dialogue with MH is already

underway

Command is often not aware of the problem up front; if the problem is 

serious, the MH professional needs to inform command either with the 

patient’s consent (which he is usually willing to give after he has 

overcome his shame and entered into treatment) or via a profile 

 If it is a mild depression, the patient may choose to keep it 

confidential (like any other medical problem that is not going to

interfere with his performance of duty)

For the younger cohort, this tension (confidentiality vs. 

command’s need to know) is less of an issue; command 

usually already knows; in those cases where they don’t, the 

Soldier is usually close to getting into some kind of 

difficulty, thus making it in his best interest to be proactive 

and letting his superiors know that he is addressing the 

underlying issues, before real trouble hits 

 For this cohort, MH contact, in actual practice, looks 

almost like ADAPCP and Family Advocacy, which are 

command programs 

For the older cohort MH patient, here is a built in tension between these 

two essential components:

 Command’s need to know 

 (which is always there in the serious cases; it is the MH professional’s

responsibility to inform command—by profile if necessary) 

 vs. 

 Assurances of confidentiality

 (so important in countering the shame of clinical depression: makes it

safe for the Soldier [or for his colleague in whom he may have

confided] to believe it is safe to “self refer” early in the process and get 

the needed care for a very treatable condition) 

D-63
Annex D – Definitions 

Anxiety disorder – an unpleasant feeling or fear or apprehension accompanied by increased 

physiological arousal, defined according to clinically derived standard psychiatric diagnostic 

criteria. 

Behavioral health services – health services specially designed for the care and treatment of 

people with mental & behavioral health problems, including mental illness. Identical to the 

definition of mental health services. 

Biopsychosocial approach – an approach to suicide prevention that focuses on those biological 

and psychological and social factors that may be causes, correlates, and/or consequences of 

mental health and mental illness and that may affect suicidal behavior. 

Bipolar disorder – a mood disorder characterized by the presence or history of manic episodes, 

usually, but not necessarily, alternating with depressive episodes. 

Cognitive/cognition – the general ability to organize, process, and recall information. 

Comprehensive suicide prevention plans – plans that use multifaceted approaches to 

addressing the problem; for example, including interventions targeting biopsychosocial, social, 

and environmental factors. 

Comorbidity – the co-occurrence of two of more disorders, such as depressive disorder with 

substance abuse disorder. 

Connectedness – closeness to an individual, group or people within a specific organization; 

perceived caring by others; satisfaction with relationship to others, or feeling loved and wanted 

by others. 

Contagion – a phenomenon whereby susceptible persons are influenced toward suicide 

behavior as a result of some other suicide behavior via personal proximity or other source of 

influential information. 

Depression – a constellation of emotion, cognitive and somatic signs and symptoms, including 

sustained sad mood or lack of pleasure. 

Epidemiological analysis – empirical examination of the incidence, distribution and potential risk 

factors for suicide. 

Equivocal Death – A death in which the means or circumstances are unclear, uncertain, or 

undecided. 

Gatekeepers – those individuals within a community who have face-to-face contact with large 

numbers of community members as part of their usual routine; they may be trained to identify 

persons at risk of suicide and refer them to treatment or supporting services as appropriate. 

Identified as either a “primary” or a “secondary” gatekeeper as defined in para 6-2b. 

Health – the complete state of physical, mental, and social well being, not merely the absence 

of disease or infirmity. 

D-64
Healthy People 2010 – the national prevention initiative that identifies opportunities to improve 

the health of all Americans, with specific and measurable objectives to be met by 2010. 

Indicated prevention intervention – intervention designed for individuals at high risk for a 

condition or disorder or those who have already exhibited the condition or disorder.

Intentional – injuries resulting from purposeful human action whether directed at oneself (selfdirected) or others (assaultive), sometimes referred to as violent injuries.

Intervention – a strategy or approach that is intended to prevent an outcome or to alter the 

course of an existing condition. 

Means – the instrument or object whereby a self-destructive act is carried out. 

Means restriction – techniques, policies, and procedures designed to reduce access or 

availability to means and methods of deliberate self-harm. 

Methods – actions or techniques which result in an individual inflicting self-harm (i.e., 

asphyxiation, overdose, jumping). 

Mental disorder – a diagnosable illness (using guidelines contained in the APA’s DSM-IV or 

later editions) characterized by alterations in thinking, mood, or behavior (or some combination 

thereof) associated with distress that significantly interferes with an individual’s cognitive, 

emotional, occupational or social abilities; often used interchangeably with mental illness. 

Mental health – the capacity of individuals to interact with one another and the environment in 

ways that promote subjective well-being, optimal development and use of mental abilities. 

Mental health problem – diminished cognitive, social or emotional abilities, but not sufficient to 

meet the criteria for a mental disorder. 

Mental health services – health services that are specially designed for the care and treatment 

of people with mental health problems, including mental illness. Identical to the definition of 

behavioral health services. 

Mental illness – see mental disorder.

Mood disorders – a term used to describe all those mental disorders that are characterized by a 

prominent or persistent mood disturbance; disturbances can be in the direction of elevated 

expansive emotional states, or, if in the opposite direction, depressed emotional states. 

Morbidity – the relative frequency of illness or injury, or the illness or injury rate, in a community 

or population. 

Non-fatal suicide events – any intent to inflict self-harm that does not result in death, but with 

apparent motivation to cause one’s own death. 

Personality disorders – a class of mental disorders characterized by deeply ingrained, often 

inflexible, maladaptive patterns or relating, perceiving, and thinking of sufficient severity to 

cause either impairment in functioning or distress. 

D-65
Post-intervention – a strategy or approach implemented after a crisis or traumatic event has 

occurred. 

Post-event data collection – required data collection and review process in the aftermath of a 

suicide to improve suicide prevention efforts. 

Prevention – a strategy or approach that reduces the likelihood of risk of onset, or delays the 

onset of adverse health problems or reduces the harm resulting from conditions or behaviors. 

Protective factors – factors that make it less likely that individuals will develop a disorder. 

Protective factors may encompass biological, psychological or social factors in the individual, 

family and environment.

Psychiatric disorder – see mental disorder. 

Psychiatry – the medical science that deals with the origin, diagnosis, prevention, and treatment 

of mental disorders. 

Psychology – science concerned with the individual behavior of humans, including mental and 

physiological processes related to behavior. 

Public informational campaigns – large scale efforts designed to provide facts to the general 

public through various media such as radio, television, advertisements, newspapers, 

magazines, and billboards. 

Rate – the number per unit of the population with a particular characteristic, for a given unit of 

time. 

Resilience – capacities within a person that promote positive outcomes, such as mental health 

and well-being, and provide protection from factors that might otherwise place that person at 

risk for adverse health outcomes. 

Risk factors – those factors that make it more likely that individuals will develop a disorder. Risk 

factors may encompass biological, psychological or social factors in the individual, family and 

environment. 

Screening – administration of an assessment tool to identify persons in need of more in-depth 

evaluation or treatment. 

Screening tools – those instruments and techniques (questionnaires, check lists, selfassessments forms) used to evaluate individuals for increased risk of certain health problems. 

Selective prevention intervention – intervention targeted to subgroups of the population whose 

risk of developing a health problem is significantly higher than average. 

Self-harm – the various methods by which individuals injure themselves, such as self-laceration, 

self-battering, taking overdoses or deliberate recklessness. 

Self-injury – see self-harm. 

D-66
Social services – organized efforts to advance human welfare, such as home-delivered meal 

programs, support groups, and community recreation projects. 

Social support – assistance that may include companionship, emotional backing, cognitive 

guidance, material aid and special services. 

Stigma – an object, idea, or label associated with disgrace or reproach. 

Substance abuse – a maladaptive pattern of substance use manifested by recurrent and 

significant adverse consequences related to repeated use. Includes maladaptive use of legal 

substances such as alcohol; prescription drugs; and illicit drugs. 

Suicidal act (also referred to as suicide attempt) – a potentially self-injurious behavior for which 

there is evidence that the person probably intended to kill himself or herself; a suicidal act may 

result in death, injuries, or no injuries. 

Suicide behaviors – includes a broad range of self-destructive or self-injurious behaviors, 

including threats, attempts and completions. 

Suicidal ideation – self-reported thoughts of engaging in suicide-related behavior. 

Suicidality – a term that encompasses suicidal thoughts, ideation, plans, suicide attempts, and 

completed suicide. 

Suicide - death resulting from the intention of the deceased to cause his or her own death. 

Suicide attempt – a potentially self-injurious behavior with a nonfatal outcome, for which there is 

evidence that the person intended to kill himself or herself; a suicide attempt may or may not 

result in injuries. 

Suicide survivors – family members, significant others, or acquaintances who have experienced 

the loss of a loved one due to suicide. 

Suicide threat - statement expressing or implying an intent to cause one’s own death. 

Suicide-related behaviors — intentional behaviors potentially resulting in serious injury or risk 

but may be motivated by an individual’s desire for assistance rather than an intent to cause his 

or her own death. 

Surveillance – Service directed data collection and review process designed to improve suicide

prevention efforts through analysis and interpretation of health data with timely dissemination of 

findings. 

Unintentional – term used for an injury unplanned or accidental injuries.

Universal preventive intervention – intervention targeted to a defined population, regardless of 

risk. 

D-67
Annex E – Abbreviations/Acronyms 

AAFES – Army Air Force Exchange Service 

AAS – American Association of Suicidology 

ACE – Adverse Childhood Experiences 

ACS – Army Community Service 

ADAPCP – Alcohol and Drug Abuse Prevention and Control Program 

AIT – Advanced Individual Training 

AMEDD – Army Medical Departments 

ASIST – Applied Suicide Intervention Skills Training 

ASPP – Army Suicide Prevention Program 

BSRF – Building Strong and Ready Families 

CDC – Center for Disease Control and Prevention 

CFSC – Community & Family Support Center 

CID – Central Investigative Division 

CCH – Chief of Chaplains 

CPO – Civilian Personnel Office 

CSA – Chief of Staff, Army 

CSSR – Completed Suicide Surveillance Report 

CY – Calendar Year 

DCSPER – Deputy Chief of Staff for Personnel 

DoD – Department of Defense 

ETOH – Ethyl Alcohol 

FAP – Family Advocacy Program 

GSW – Gunshot Wound

IET – Intial Entry Training 

IG – Inspector General 

IO – Investigating Officer 

ISRT – Installation Suicide Response Team 

ISPC – Installation Suicide Prevention Committee 

MACOMs – Major Army Commands 

MEDCOM – Medical Command 

MH – Mental Health 

MHO – Mental Health Officer 

D-68
MP – Military Police 

MTF – Medical Treatment Facility 

MUSARC/RSC – Major United States Army Reserve Command/Regional Support Command 

MWR – Morale, Welfare, and Recreation 

NAMI – National Alliance for the Mentally Ill 

NCHS – National Center for Health Statistics 

NGB – National Guard Bureau 

OCCH – Office of the Chief of Chaplains 

ODCSPER – Office of the Deputy Chief of Staff for Personnel 

ODPHP – Office of Disease Prevention and Health Promotion 

OTSG – Office of the Surgeon General 

PA – Psychological Autopsy 

PAO – Public Affairs Office 

RAP – Recruit Assessment Program 

SAR – Suicide Analysis Report 

SMA – Sergeants Major of the Army 

SPRRC – Suicide Prevention Risk Reduction Committee 

TJAG – The Judge Advocate General 

TSG – The Surgeon General (Army) 

TRADOC – Training and Doctrine Command 

UCMJ – Uniform Code of Military Justice 

UMT – Unit Ministry Team 

USACHPPM – US Army Center for Health Promotion and Preventive Medicine 

USACIC – US Army Central Investigation Command 

USARC – US Army Reserve Command 

USC – United States Code 

VA – Veterans Administration 

VCSA – Vice Chief of Staff, Army 

WRAIR – Walter Reed Army Institute of Research 

WRAMC – Walter Reed Army Medical Center

D-69
Annex F - References 

1. Healthy People 2010, Office of Disease Prevention and Health Promotion, U.S. Department 

of Health of Human Services 

2. National Alliance for the Mentally Ill Fact Sheet, October 2000 

3. Tondo L, Baldessarini R, Suicide: An Overview, Psychiatry Clinical Management, Volume 3, 

2001. 

4. Zill, Robinson, The Generation X, American Demographics, 1995, 24-33. 

5. Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, Koss M, Marks J, 

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of 

Deaths in Adults: The Adverse Childhood Experiences (ACE) Study, American Journal of 

Preventive Medicine, 1998; 14(4) 

6. Legree, Generation X: Motivation, Morals, and Values, Army Research Institute Special 

Report, June 1997 

7. Naval Health Research Center Report #95-26, Pre-enlistment Maltreatment Histories of U.S. 

Navy Basic Trainees: Prevalance of Abusive Behaviors, 1995 

8. Hendin, H., Chapter 33, Psychiatric Emergencies, The Psychiatric Syndromes 

9. Jobes D, Mann R, Reasons for Living versus Reasons for Dying: Examing the Internal 

Debate of Suicide, Suicide and Life-Threatening Behavior, Vol. 29(2), Summer 1999

Other References 

Shaffer D, Suicide and Suicide Prevention in the Military Forces, A Report of a Consultation, 

Aug 97 

National Strategy for Suicide Prevention, Goals and Objectives for Action, May 2001 

Military

DA PAM 600-24, Suicide Prevention and Psychological Autopsy 

AR 600-5, Health Promotion 

AR 190-40, Serious Incident Report 

DoD Suicide Prevention and Risk Reduction Committee Charter 

D-70
Annex G – Useful Web Sites/Contacts 

• American Assocation for Suicidology, (www.suicidology.org) 

• American Foundation for Suicide Prevention, (www.afsp.org) 

• Army Administrative Electronic Publication website, (www.usapa.army.mil/gils/) 

• Living Works Education, (www.livingworks.net) 

• Healthy People 2010, (www.health.gov/healthypeople) 

• National Suicide Prevention Web site (copies of the National Strategy Summary Booklet) 

(www.mentalhealth.org/suicideprevention) 

• ODCSPER Suicide Prevention Web Site, 

(www.odcsper.army.mil/default.asp?pageid=66f) 

• Organization of Attempters and Survivors of Suicide in Interfaith Service, 

(www.oassis.org) 

• Suicide Awareness\Voices of Education, (www.save.org) 

• Suicide Prevention Advocacy Network, (www.spanusa.org) 

• Surgeon General’s Call to Action, (www.surgeongeneral.gov/library/calltoaction) 

• U.S. Army Center for Health Promotion and Preventive Medicine, 

(chppm-www.apgea.army.mil) 

Phone Numbers: 

• National Suicide Hotline: 1-800-suicide (800) 784-2433 

 

D-71
Army Suicide Demographics 

Suicide can affect anyone, regardless of rank, age, sex, MOS, race or ethnicity. Although there 

are no select demographics that will accurately predict suicidal behavior with certainty, it is 

important to examine the Army suicide population in an attempt to infer potential suicide risk 

indicators for use in prevention efforts (an updated briefing of the previous calendar year as well 

as the current monthly Army suicide statistics and demographics can be found at the Army G-1 

HRPD website). Our vigilance and awareness must extend to everyone in The Army. It is also 

important not to use demographics to “profile” or “discriminate” at-risk populations. 

Suicide Methods 

Suicide by self-inflicted gun shot wound (GSW) was the most common method chosen by 

Soldiers, followed by hanging, carbon monoxide poisoning and drug overdose. Other methods 

include poisoning, burns, jumping and stabbing. Nationally, suicide by firearms was the most 

chosen method resulting in fifty-seven percent of all suicidal deaths in the United States. 

Generally, men tend to choose more violent, lethal means (GSW, hanging, and jumping). 

Women generally prefer less-violent means (drug overdose, and wrist cutting) but recent data 

suggest an increasing use of firearms by American women. 

According to AAS, those who own a gun are 32 times more likely to commit suicide than those 

who do not own a gun. This figure doesn’t suggest that people who own guns are more likely to 

be suicidal, but rather the potential impact of having an immediate, convenient and highly lethal 

means to carry out the suicide act once the decision has been made. In fact, approximately 83 

percent of fatal gunshot wounds are associated with suicides, compared to 7 percent for 

homicides committed by relatives, 3 percent associated with accidents, and only 2 percent of 

deaths involving strangers. Purchasing a weapon is associated with a dramatic increase in the 

risk of suicide in the ensuring year following the purchase. 

D-72
APPENDIX 5 (AMEDD Suicide Event Report (ASER), Pilot Version-V.31 January

2003) to ANNEX D to OIF MHAT REPORT 

D-73
AMEDD Suicide Event Report ASER Version: 2.01 (04-Mar-2004) 

Previous editions are obsolete.

• This form is to be completed for suicide behaviors that result in death, hospitalization, and/or evacuation. 

• Complete all information as it applied at the time of event. 

• Select only one box per question unless directed otherwise.

I. Event Information 

Event date: (dd-mmm-yy, can be entered mm.dd.yy or mm/dd/yy)

Type of event: 

(check all that apply) Completed suicide 

Hospitalized 

Evacuated 

Other: 

Severity of event: “Medical” intervention not required 

Required “medical” intervention but was not life-threatening

Required “medical” intervention and likely fatal without 

treatment

Was fatal 

Yes 

No 

Don't know

Did event result in 

hospitalization? 

If yes, what type of facility? 

MTF 

Civilian facility 

VA Hospital 

What was the name of the facility? 

Admission date? (dd-mmm-yy)

Discharge date? (dd-mmm-yy)

Was the event related to a 

deployment? 

Yes, anticipated deployment 

Yes, current deployment 

Yes, post-deployment 

No 

1.

2. 

3. 

4. 

5. 

ASER p 1 of 12

D-74
If yes,

Start date of deployment? (dd-mmm-yy)

End date of deployment? (dd-mmm-yy)

Deployment location? 

Afghanistan Kosovo 

Iraq Kuwait 

Korea Other: 

ASER p 2 of 12

D-75
I. Event Information (continued) 

Yes

No

Did patient/decedent

communicate intent to others? 

If yes, to whom? (check all that apply)

Supervisor 

Chaplain 

Friend

Mental Health staff 

Spouse or significant other 

Other: 

Overdose

If overdose, select method: 

Prescription medication 

Over-the-counter medication 

Illicit drugs

Primary method used: 

Poisoning by solid or liquid substance (not medication)

Firearm / gun

Jumping from high place 

Motor vehicle crash 

Hanging, strangulation, or suffocation 

Cutting or piercing instrument 

Poisoning by vehicle exhaust 

Poisoning by utility gas 

Submersion (drowning) 

Other: 

Don’t know

During the event, were drugs 

used? 

Yes

No 

Don’t know

During the event, was alcohol 

used? 

Yes

No 

Don’t know

Was event committed in public 

place where it would likely be 

observed and intervened in by 

others? 

Yes

No 

Don’t know

The event was... Planned, deliberate, and/or premeditated 

Impulsive and/or unplanned

Don’t know

6.

7. 

8. 

9. 

10. 

11. 

ASER p 3 of 12

D-76
II. Patient/Decedent Personal Information 

Last name: 

First name & middle initial: ,

Social Security Number: 

Date of birth: (dd-mmm-yy)

Sex: Male 

Female 

Residence: Barracks 

BEQ / BOQ 

On-post family housing 

Off-post housing

Resides alone: Yes 

No 

Don't know

Education: Did not complete high school 

GED 

High school graduate 

Two-year college degree

Four-year college degree or greater

Race/population: American Indian 

Asian 

Black 

White 

Other: 

Don’t know

Ethnic group: Mexican Japanese 

Puerto Rican Korean 

Cuban Indian 

Latin American Filipino 

Other Spanish Vietnamese 

Aleut Other Asian 

Eskimo Melanesian

U.S/Canadian Indian Tribes Polynesian 

Chinese Other Pacific Islands 

Other: 

Don’t know

12.

13. 

14.

15.

16.

17.

18.

19.

ASER p 4 of 12

D-77
20. Marital status: 

(check only one)

Married, resides with spouse

Married, geographically separated

Widowed

Divorced 

Separated, legally or due to relationship problems 

Don’t know

ASER p 5 of 12

D-78
II. Patient/Decedent Personal Information (continued) 

Yes

No 

Don’t know

Minor children? 

If yes, were the children residing with him/her? 

Yes

No 

Don’t know

III. Sponsor’s Military Information 

Service: Army 

Navy 

Air Force 

Marines 

Coast Guard 

Other: 

Component: Regular (e.g. Army, Air Force) 

Reserve 

National Guard 

DOD civilian / contractor

Duty status:

(check all that apply)

Active Duty 

AGR 

IET (Basic and Advanced Individualized Training) 

Mobilized RC (Reserve and National Guard) 

ADT (Active Duty for Training) 

IDT (Weekend Reserve Drill) 

Retired 

Other: 

Rank: Enlisted 1 6

Warrant Officer 2 7 

Officer 3 8 

Cadet / Midshipman 4 9 

 5 10 

Relationship to sponsor: Sponsor 

Spouse 

Child 

Other: 

MOS:

(Military Occupation Specialty Code)

Division: 

Brigade: 

21.

22.

23.

24.

25.

26. 

27.

28.

ASER p 6 of 12

D-79
Battalion: 

Company: 

ASER p 7 of 12

D-80
III. Sponsor’s Military Information (continued) 

UIC:

(Unit Identification Code)

Permanent duty station / 

installation: 

City: 

State: 

Country:

Length of time in unit: years, months Check if unknown 

Duty environment/status at time 

of event: 

(check all that apply)

Garrison Psychiatric hospitalization

Leave Medical hold

TDY In evacuation chain 

AWOL Under command observation (e.g. CIP) 

Deployed Other: 

Training

IV. Combat 

Did the patient/decedent

recently... Yes No Don’t know

experience direct combat 

operations? 

have a close friend or unit 

member killed or seriously

wounded in combat operations? 

witness others (civilians, enemy 

combatants, unknown Soldiers) 

killed or seriously wounded while 

participating in combat 

operations? 

V. Use of Medical and Helping Services Prior to the Event 

In the past year was the 

patient/decedent seen by... 

Yes within 30 days 

before event

Yes

31-365 days 

before event No Don’t know

Medical Treatment Facility

Substance Abuse Services? 

Family Advocacy Program?

Out-Patient Mental Health? 

(including deployment mental 

health services)

In-Patient Mental Health? 

29.

30. 

31. 

32. 

33.

34. 

35. 

36. 

37. 

38. 

39.

40.

ASER p 8 of 12

D-81
VI. Risk Factors 

If yes, is there a 

pending, related... 

Had the patient/decedent... Yes No Don’t know MEB? 

admin. 

separation?

been diagnosed with any Mood 

Disorder? 

been diagnosed with Bipolar 

Disorder? 

been diagnosed with Major 

Depression?

been diagnosed with Psychotic 

Disorder? 

been diagnosed with PTSD? 

been diagnosed with Anxiety 

Disorder? 

been diagnosed with Personality 

Disorder? 

had a history with Substance 

Abuse?

If yes, select all that apply: 

 Dependence Abuse 

Alcohol

Drugs

Medications, prescribed

Medications, not prescribed

(e.g. OTC medication) 

been taking psychotropic 

medications?

had a family history of mental 

illness or suicide? 

had prior self-injurious events? 

If yes,

One prior event 

More than one prior event 

Was this event similar to prior event(s)? 

Yes

No 

Don’t know

Was there a gun in the home or 

immediate environment? 

41. 

42. 

43. 

44. 

45. 

46. 

47. 

48. 

49. 

50. 

51. 

52. 

ASER p 9 of 12 

D-82
VII. Relationships 

Yes No Don’t know

Was the patient/decedent 

involved in a failed/failing 

intimate relationship? 

Was there a recent spousal or 

family death?

Is there an ongoing spousal or 

family severe illness? 

VIII. Motivation 

What was the patient/ 

decedent’s primary motivation 

for committing suicide? 

(as judged by the clinician)

A wish to escape from mental or physical pain 

A fantasy of eternal rest or life with a loved one 

Anger, rage, revenge 

Guilt, shame, atonement 

A wish to be rescued, reborn, start over 

A wish to make an important statement or communication 

Other: 

Don’t know

IX. Abuse and Trauma History

Was the patient/decedent 

a recent victim of... Yes No Don’t know

physical, sexual, or emotional 

abuse/assault? (e.g. FAP) 

sexual harassment? 

X. Military, Legal, and Administrative History

Was the patient/decedent 

an alleged or confirmed 

perpetrator of recent... Yes No Don’t know

physical, sexual, emotional, or 

verbal abuse (e.g. FAP)? 

sexual harassment? 

Was the patient/decedent recently

involved in... Yes No Don’t know

Courts Martial proceedings? 

Article 15 proceedings? 

Administrative Separation 

proceedings?

AWOL or desertion 

proceedings? 

non-selection for advanced

schooling / promotion / 

command? 

53. 

54. 

55. 

56. 

57. 

58.

59. 

60.

61. 

62. 

63.

64. 

65. 

ASER p 10 of 12

D-83
XI. Work Problems 

Did the patient/decedent... Yes No Don’t know

experience work dissatisfaction? 

have supervisor/coworker 

issues/problems? 

have a poor work performance 

review or evaluation? (e.g. bar 

for reenlistment, flagged record, 

extra duty imposed) 

experience recent unit or 

workplace hazing? 

have any other experiences at 

work which may have led to the 

event? 

If yes, what other experiences? 

 

XII. Financial Problems 

Did the patient/decedent... Yes No Don’t know

have excessive debt? 

experience bankruptcy? 

XIII. Completing Behavioral Health Provider's Information 

Name:

Phone number: 

Phone number (DSN): 

Email: 

Comments: 

66. 

67.

68. 

69. 

70. 

71. 

72. 

73.

ASER p 11 of 12

D-84
XIV. Narrative Summary

Sequence of events culminating 

in the suicide behavior: 

(Describe the details of the antecedent 

circumstances that led to the suicide 

attempt/completion)

Why did this patient/decedent 

choose to injure or kill 

him/herself? 

(Provide a brief "bio-psycho-social" 

formulation as to WHY this patient

committed the suicide 

attempt/completion) 

Risk management analysis: 

(Any BH clinical involvement - elaborate 

on any issue of concern. Also elaborate 

on unit actions that may have 

contributed)

74. 

75. 

76. 

ASER p 12 of 12

D-85
Acknowledgements 

We would like to thank COL ------------------ for his technical assistance and consultation, 

and to the WRAIR Neuropsychiatry staff for literature review. 

D-86